Ovarian cancer carries a marginal level of mutational load.11
Preliminary efficacy with checkpoint inhibitors was tested in a population with recurrent unselected heavily pretreated ovarian cancer and produced an overall response rate (ORR) of 5.9% to 15%.12,13
Nivolumab (Opdivo) has demonstrated a response rate of 15% in PD-L1–positive platinum- resistant ovarian cancer.12
Recently, Matulonis et al14
reported the results of KEYNOTE-100 (NCT02674061). This study evaluated the role of pembrolizumab (Keytruda) in patients with advanced recurrent ovarian cancer. Patients received pembrolizumab at 200 mg IV every 3 weeks for 2 years or until progression, death, or unacceptable toxicity. The primary endpoint of the study was ORR by RECIST v1.1. The effect of PD-L1 expression on ORR was tested with a combined positive score assay. Overall, 378 patients were enrolled in KEYNOTE-100. The ORR was 9% (95% CI, 4%-17%) and was higher in patients with PD-L1 expression: 14% with a combined positive score ≥1 and 25% with a composite positive score of ≥10.
NRG-GY003 (NCT02498600) is a randomized, open-label, phase II trial evaluating the safety and efficacy of nivolumab with or without ipilimumab (Yervoy) as a therapy for patients with persistent or recurrent epithelial ovarian, primary peritoneal, or fallopian tube cancer. This 2-arm trial has completed accrual (n = 96), with data expected in late 2020 or early 2021.
There is evidence that chemotherapeutic agents may modulate the tumor microenvironment, and there is potential that treatment could be enhanced by the addition of immune checkpoint inhibitors targeting PD-1 or PD-L1. Preclinical evidence for chemotherapy and PD-L1 inhibitors showed synergism of nab-paclitaxel (Abraxane) plus PD-L1 inhibition in MC38 mouse tumor models.15
Treatment with platinum agents or taxanes increased the percentage of CD8-positive tumor-infiltrating lymphocytes in immunocompetent mouse models.
Several trials are combining chemotherapy with checkpoint blockade. The results of 2 studies testing the activity of avelumab (Bavencio) in combination regimens have been reported. The JAVELIN OVARIAN 100 trial (NCT02718417) was terminated in December after a planned interim analysis showed that the experimental combination would not result in improved PFS, according to Merck KGaA and Pfizer, the companies developing the therapy.16
This JAVELIN OVARIAN 100 trial was a randomized phase III study in previously untreated patients with stage III to IV ovarian, fallopian tube, or peritoneal cancer. Patients were randomized 1:1 to 1 of 3 arms. Arm 1 included cytotoxic chemotherapy with carboplatin and paclitaxel followed by observation, arm 2 included chemotherapy with carboplatin and paclitaxel followed by avelumab every 2 weeks, and arm 3 included cytotoxic chemotherapy with carboplatin and paclitaxel plus avelumab every 3 weeks followed by avelumab as maintenance therapy. The primary endpoint of the study was PFS and the secondary endpoints included maintenance PFS and OS, ORR, duration of response, and patient-reported outcomes and safety.
In November 2018, the JAVELIN Ovarian 200 (NCT02580058) failed to meet the primary endpoints of improved PFS and OS, according to Merck KGaA and Pfizer.17
The trial enrolled patients with platinum-resistant ovarian cancer to either pegylated liposomal doxorubicin (PLD) plus avelumab or PLD alone.
Given the known role of PARP inhibitors in the management of ovarian cancer, investigators also are exploring whether PARP inhibitors can strengthen immune system response. PARP inhibitors can increase lymphocyte infiltration. The rationale behind this finding is that PARP inhibitors can lead to accumulation of DNA damage and cytoplasmic DNA, which stimulates the interferon gene-dependent immune response.18
Growing evidence supports the preclinical rationale for combining immune checkpoint inhibitors with DNA-damaging agents.
Recently, 2 trials highlighted the efficacy of combination treatment with a PARP inhibitor plus an immune checkpoint inhibitor in patients with ovarian cancer. The MEDIOLA trial19
treated 30 patients with relapsed, platinum-sensitive, BRCA
-mutated ovarian cancer with a combination of olaparib and the immune checkpoint inhibitor durvalumab (Imfinzi). Drew et al reported an ORR of 72% and a disease control rate of 81%. TOPACIO20
presented by Konstantinopoulos et al enrolled 62 patients with recurrent ovarian cancer treated with niraparib (200 mg oral daily) and pembrolizumab (200 mg IV on a 21-day cycle). The ORR was 25% and the disease control rate was 67%.
Numerous trials are exploring the role of combinatorial therapy with PARP inhibitors and checkpoint inhibitors in patients with newly diagnosed ovarian cancer (Table 2
). In conclusion, the treatment options for patients with ovarian cancer have made a tremendous leap forward. Encouragement in clinical trials will pave the path for continued success.
- Burger RA, Brady MF, Bookman MA, et al; Gynecologic Oncology Group. Incorporation of bevacizumab in the primary treatment of ovarian cancer. N Engl J Med. 2011;365(26):2473-2483. doi: 10.1056/NEJMoa1104390.
- Oza AM, Cook AD, Pfisterer J, et al; ICON7 trial investigators. Standard chemotherapy with or without bevacizumab for women with newly diagnosed ovarian cancer (ICON7): overall survival results of a phase 3 randomised trial. Lancet Oncol. 2015;16(8):928-936. doi: 10.1016/S1470-2045(15)00086-8.
- Kaufman B, Shapira-Frommer R, Schmutzler RK, et al. Olaparib monotherapy in patients with advanced cancer and a germline BRCA1/2 mutation. J Clin Oncol. 2015;33(3):244-250. doi: 10.1200/JCO.2014.56.2728.
- Swisher EM, Lin KK, Oza AM, et al. Rucaparib in relapsed, platinum-sensitive high-grade ovarian carcinoma (ARIEL2 part 1): an international, multicentre, open-label, phase 2 trial. Lancet Oncol. 2017;18(1):75-87. doi: 10.1016/S1470-2045(16)30559-9.
- Mirza MR, Monk BJ, Herrstedt J, et al; ENGOT-OV16/NOVA Investigators. Niraparib maintenance therapy in platinum-sensitive, recurrent ovarian cancer. N Engl J Med. 2016;375(22):2154-2164. doi: 10.1056/NEJMoa1611310.
- Pujade-Lauraine E, Ledermann JA, Selle F, et al; SOLO2/ENGOT-Ov21 investigators. Olaparib tablets as maintenance therapy in patients with platinum-sensitive, relapsed ovarian cancer and a BRCA1/2 mutation (SOLO2/ENGOT-Ov21): a double-blind, randomised, placebo-controlled, phase 3 trial. Lancet Oncol. 2017;18(9):1274-1284. doi: 10.1016/S1470-2045(17)30469-2.
- Ledermann JA, Harter P, Gourley C, et al. Overall survival in patients with platinum-sensitive recurrent serous ovarian cancer receiving olaparib maintenance monotherapy: an updated analysis from a randomised, placebo-controlled, double-blind, phase 2 trial. Lancet Oncol. 2016;17(11):1579-1589. doi: 10.1016/S1470-2045(16)30376-X.
- Coleman RL, Oza AM, Lorusso D, et al; ARIEL3 investigators. Rucaparib maintenance treatment for recurrent ovarian carcinoma after response to platinum therapy (ARIEL3): a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet. 2017;390(10106):1949-1961. doi: 10.1016/S0140-6736(17)32440-6.
- Lynparza [prescribing information]. Wilmington, Del: AstraZeneca Pharmaceuticals; 2018. accessdata.fda.gov/drugsatfda_docs/label/2018/208558s006lbl.pdf. Accessed January 17, 2019.
- Moore K, Colombo N, Scambia G, et al. Maintenance olaparib in patients with newly diagnosed advanced ovarian cancer [published online October 21, 2018]. N Engl J Med. doi: 10.1056/NEJMoa1810858.
- Zehir A, Benayed R, Shah RH, et al. Mutational landscape of metastatic cancer revealed from prospective clinical sequencing of 10,000 patients. Nat Med. 2017;23(6):703-713. doi: 10.1038/nm.4333.
- Hamanishi J, Mandai M, Ikeda T, et al. Safety and antitumor ativity of anti-PD-1 antibody, nivolumab, in patients with platinum-resistant ovarian cancer. J Clin Oncol. 2015;33(34):4015-1022. doi: 10.1200/JCO.2015.62.3397.
- Varga A, Piha-Paul SA, Ott PA, et al. Antitumor activity and safety of pembrolizumab in patients (pts) with PD-L1 positive advanced ovarian cancer: Interim results from a phase Ib study. J Clin Oncol. 2015;33(15_suppl):5510-5510.
- Matulonis UA, Shapira-Frommer R, Santin A, et al. Antitumor activity and safety of pembrolizumab in patients with advanced recurrent ovarian cancer: interim results from the phase 2 KEYNOTE-100 study. Presented at: 2018 ASCO Annual Meeting; June 1-5, 2018; Chicago, IL. Abstract 5511. meetinglibrary.asco.org/record/162042/abstract.
- Adams S, Diamond J, Hamilton E, et al. Safety and clinical activity of atezolizumab (anti-PDL1) in combination with nab-paclitaxel in patients with metastatic triple-negative breast cancer. Presented at: 2015 San Antonio Breast Cancer Symposium; December 8-12, 2015; San Antonio, TX. Abstract P2-11-06.
- Merck KGaA, Darmstadt, Germany, and Pfizer provide update on JAVELIN Ovarian 100 trial of avelumab in previously untreated advanced ovarian cancer [news release]. Darmstadt, Germany and New York, NY: Merck KGaA and Pfizer Inc; December 21, 2018. pfizer.com/news/press-release/press-release-detail/merck_kgaa_darmstadt_germany_and_pfizer_provide_update_on_javelin_ovarian_100_trial_of_avelumab_in_previously_untreated_advanced_ovarian_cancer. Accessed January 17, 2019.
- Merck KGaA, Darmstadt, Germany, and Pfizer provide update on avelumab in platinum-resistant/refractory ovarian cancer [news release]. Darmstadt, Germany and New York, NY: Merck KGaA and Pfizer Inc; November 19, 2018. pfizer.com/news/press-release/press-release-detail/merck_kgaa_darmstadt_germany_and_pfizer_provide_update_on_avelumab_in_platinum_resistant_refractory_ovarian_cancer. Accessed January 17, 2019.
- Harding SM, Benci JL, Irianto J, Discher DE, Minn AJ, Greenberg RA. Mitotic progression following DNA damage enables pattern recognition within micronuclei. Nature. 2017;548(7668):466-470. doi: 10.1038/nature23470.
- Drew Y, de Jonge M, Hong S-H, et al. An open-label, phase II basket study of olaparib and durvalumab (MEDIOLA): Results in germline BRCA-mutated (gBRCAm) platinum-sensitive relapsed (PSR) ovarian cancer (OC). Presented at: SGO Annual Meeting; March 24-27, 2018; New Orleans, LA. gynecologiconcology-online.net/article/S0090-8258(18)30833-3/abstract.
- Konstantinopoulos PA, Sachdev JC, Schwartzberg L, et al. Dose-finding combination study of niraparib and pembrolizumab in patients (pts) with metastatic triple-negative breast cancer (TNBC) or recurrent platinum-resistant epithelial ovarian cancer (OC) (TOPACIO/Keynote-162). Presented at: 2017 ESMO Congress; September 8-12, 2017; Madrid, Spain. Abstract 1143PD. academic.oup.com/annonc/article/28/suppl_5/mdx376.009/4109223.