NRG-GY012: Randomized phase 2 study comparing olaparib, cediranib, and the combination of cediranib/olaparib in women with recurrent, persistent, or metastatic endometrial cancer.

PURPOSE: This paper reports the efficacy of the poly (ADP-ribose) polymerase inhibitor olaparib alone and in combination with the antiangiogenesis agent cediranib compared with cediranib alone in patients with advanced endometrial cancer. METHODS: This was open-label, randomized, phase 2 trial (NCT03660826). Eligible patients had recurrent endometrial cancer, received at least one (<3) prior lines of chemotherapy, and were Eastern Cooperative Oncology Group performance status 0 to 2. Patients were randomly assigned (1:1:1), stratified by histology (serous vs. other) to receive cediranib alone (reference arm), olaparib, or olaparib and cediranib for 28-day cycles until progression or unacceptable toxicity. The primary end point was progression-free survival in the intention-to-treat population. Homologous repair deficiency was explored using the BROCA-GO sequencing panel. RESULTS: A total of 120 patients were enrolled and all were included in the intention-to-treat analysis. Median age was 66 (range, 41-86) years and 47 (39.2%) had serous histology. Median progression-free survival for cediranib was 3.8 months compared with 2.0 months for olaparib (hazard ratio, 1.45 [95% CI, 0.91-2.3] p = .935) and 5.5 months for olaparib/cediranib (hazard ratio, 0.7 [95% CI, 0.43-1.14] p = .064). Four patients receiving the combination had a durable response lasting more than 20 months. The most common grade 3/4 toxicities were hypertension in the cediranib (36%) and olaparib/cediranib (33%) arms, fatigue (20.5% olaparib/cediranib), and diarrhea (17.9% cediranib). The BROCA-GO panel results were not associated with response. CONCLUSION: The combination of cediranib and olaparib demonstrated modest clinical efficacy; however, the primary end point of the study was not met. The combination was safe without unexpected toxicity.

NCCN Guidelines® Insights: Ovarian Cancer, Version 3.2022.

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States, with less than half of patients living >5 years following diagnosis. The NCCN Guidelines for Ovarian Cancer provide recommendations for the diagnosis, evaluation, treatment, and follow-up for patients with ovarian, fallopian tube, and primary peritoneal cancers. These NCCN Guidelines Insights summarize the panel discussion behind recent important updates to the guidelines, including revised guidance on alternative chemotherapy regimens for patients with advanced age and/or comorbidities, a new algorithm for recurrent low-grade serous carcinoma based on developing research and novel therapeutic agents, and updated language regarding tumor molecular analysis applications in ovarian cancer.

Current and Future Directions for PARP Inhibition.

Megan Grudem, APRN, CNP, and Andrea Wahner Hendrickson, MD, reviewed the potential role of PARP inhibition in various malignancies, how to select patients who are appropriate candidates, and guidance on devising treatment plans that include PARP inhibitors for patients with ovarian or breast cancer based on genetic profiles, tolerability, dosing schedules, and other key factors.

Loratadine for Paclitaxel-Induced Myalgias and Arthralgias.

BACKGROUND: Seventy percentage of patients who receive paclitaxel have diffuse, refractory myalgias, and arthralgias. Based on anecdotal reports, this study explored whether loratadine, an antihistamine, palliates these symptoms. METHODS: The medical records of postoperative ovarian and patients with endometrial cancer were studied, as these patients are routinely prescribed paclitaxel. Records were screened for patients who received paclitaxel and loratadine concurrently. RESULTS: Forty patients are the focus of this report. Eight had paclitaxel-induced myalgias and arthralgias and then took loratadine; of these, 6 (75%; 95% confidence interval: 35%, 97%) manifested evidence of symptom improvement: "She did experience some migrating generalized body aches and pains…but this has resolved." Of those already receiving loratadine but with no myalgias and arthralgias, only 11 of 32, or 34% (95% confidence interval: 19%, 53%), developed myalgias and arthralgias (in contrast to the previously reported symptom rate of 70%). No adverse events were clearly attributed to loratadine. CONCLUSION: These preliminary data support further study of loratadine for paclitaxel-induced myalgias and arthralgias.

Can Poly (ADP-Ribose) Polymerase Inhibitors Palliate Paclitaxel-Induced Peripheral Neuropathy in Patients With Cancer?

BACKGROUND:: Paclitaxel-treated patients can suffer from years of peripheral neuropathy with pain, numbness, and tingling. Promising preclinical data with poly (ADP-ribose) polymerase (PARP) inhibitors led us to explore this class of agents to palliate this neuropathy. METHODS:: We relied on a completed trial that tested the antineoplastic effects of veliparib (NCT01012817). Data from patients who had been enrolled on NCT01012817, who previously received paclitaxel, and who had completed a validated pain assessment instrument were evaluated for improvement in their pain scores. RESULTS:: All 34 eligible patients were women, and all had a metastatic gynecological malignancy. On a 10-point scale (higher numbers indicative of worse pain), the average baseline score was 3.6 (range: 0-7). Seven patients (21%; 95% confidence interval: 9%-38%) manifested a drop in pain score (1 score lower than baseline followed by at least one consecutive value also below baseline). Of note, no patients initiated other therapy for neuropathy while on NCT01012817. CONCLUSION:: The PARP inhibitors merit further study for chemotherapy-induced peripheral neuropathy. For patients suffering from peripheral neuropathy, these putative palliative effects might prompt earlier consideration of a PARP inhibitor as part of cancer treatment.

Oncologic emergencies: Pathophysiology, presentation, diagnosis, and treatment.

Oncologic emergencies can occur at any time during the course of a malignancy, from the presenting symptom to end-stage disease. Although some of these conditions are related to cancer therapy, they are by no means confined to the period of initial diagnosis and active treatment. In the setting of recurrent malignancy, these events can occur years after the surveillance of a cancer patient has been appropriately transferred from a medical oncologist to a primary care provider. As such, awareness of a patient's cancer history and its possible complications forms an important part of any clinician's knowledge base. Prompt identification of and intervention in these emergencies can prolong survival and improve quality of life, even in the setting of terminal illness. This article reviews hypercalcemia, hyponatremia, hypoglycemia, tumor lysis syndrome, cardiac tamponade, superior vena cava syndrome, neutropenic fever, spinal cord compression, increased intracranial pressure, seizures, hyperviscosity syndrome, leukostasis, and airway obstruction in patients with malignancies. Chemotherapeutic emergencies are also addressed.

Oncologic emergencies.

Oncologic emergencies represent a wide variety of conditions that can occur at any time during the course of a malignancy, from an initial presenting manifestation in someone with an undiagnosed cancer, to end-stage incurable metastatic disease. Emergent conditions can also arise after a malignancy has been in remission for many years, even decades, so clinicians must be aware of any prior history of cancer in patients. Oncologic emergencies include conditions caused by the cancer itself or side effects of therapy. Emergent conditions include metabolic, cardiac, neurologic, or infectious disorders. Many of these emergencies are imminently life-threatening, and can occur in patients with curable disease (such as lymphomas or leukemias); however, many also present in patients with incurable advanced disease. Prompt recognition and treatment of these conditions can lead to markedly improved quality and quantity of life.

Resistance pathways relevant to insulin-like growth factor-1 receptor-targeted therapy.

The dysregulation of insulin-like growth factor (IGF) signaling has been implicated as a critical contributor to malignant transformation, proliferation, survival, migration and resistance to anticancer therapies. As a result, IGF signaling has become an attractive target for the development of novel anticancer agents, and a large number of compounds, including blocking antibodies and tyrosine kinase inhibitors targeting the key signaling kinase of the IGF system, the IGF-1 receptor (IGF-1R), are in preclinical and clinical development. Although most tumors express the IGF-1R, expression alone is unlikely to be sufficient for sensitivity to IGF-targeted treatment. An understanding of the IGF signaling system and its downstream effectors is important, as this information will allow appropriate molecular markers of sensitivity to be determined, thus providing the rationale for combining IGF-1R blockade with other therapies to overcome resistance. This review highlights some of the preclinical and early clinical data on determinants of sensitivity to IGF targeting in human cancers, and reviews the rationale for targeting other tyrosine kinases, such as the insulin receptor and members of the EGFR family, to overcome intrinsic resistance to targeted IGF-1R therapy.

Anticancer therapy: boosting the bang of Bim.

Even though activating mutations of B-Raf, a kinase atop the MAPK signaling cascade, reportedly sensitize tumor cells to MEK inhibitors, Raf and MEK inhibitors have exhibited limited clinical activity. In this issue of the JCI, Cragg et al. report that MEK inhibition upregulates the proapoptotic Bcl-2 family member Bim but induces little regression of human melanoma xenografts in mice unless the Bcl-2 antagonist ABT-737 is added (see the related article beginning on page 3651). These findings illustrate the potential benefit of simultaneously inhibiting oncogenic kinases and inhibiting Bcl-2 action in solid tumors.