Clinical Therapeutics/Volume 37, Number 1, 2015

Review Article

Exploring the Therapeutic Rationale for Blockade in Cervical

Lauren S. Krill, MD, MS; and Krishnansu S. Tewari, MD The Division of Gynecologic Oncology, University of California, Irvine Medical Center, Orange, California

ABSTRACT therapies in the future. (Clin Ther. 2015;37:9–19) Purpose: This review highlights the molecular and & 2015 Elsevier HS Journals, Inc. All rights reserved. pathologic evidence that cervical cancer is driven by Key words: angiogenesis, , recurrent angiogenesis and presents a summary of the recent cervical cancer, therapeutic rationale, anti-angiogenesis clinical research in antiangiogenesis therapy for advanced therapy. cervical cancer with a focus on the use of bevacizumab. Methods: The articles chosen for this review reveal the rationale for antiangiogenesis agents in cervical INTRODUCTION cancer from 3 perspectives: pathologic, molecular, and Since the 1950s widespread use of cervical cytologic clinical data. testing has been successful in markedly reducing the Findings: Several translational investigations have incidence and mortality of cervical cancer in devel- revealed that proangiogenic signaling cascades are oped countries and is recognized as one of the greatest active in cervical carcinogenesis and can be used to cancer prevention achievements to date. In patients improve patient outcomes in advanced disease. For with abnormal cervical cytologic test results, one of example, in a recently published study of patients with the hallmarks of invasive disease is vascular aberra- recurrent and metastatic cervical cancer, bevacizumab tions. Mosaicism, punctuations, and atypical vessels was the first targeted agent to improve overall survival are all vascular markings that can be identified in a gynecologic cancer when successfully combined colposcopically and are indicative of angiogenesis. with 2 different chemotherapy regimens. Angiogenesis is the process of formation of new blood Implications: Because of recent advances in screen- vessels in the body, which is fundamental in the ing, aggressive management of cervical intraepithelial growth of new tissues, , and embryo- neoplasia, and human papillomavirus vaccination, genesis, but is also essential for tumor proliferation, cervical cancer is preventable and curable with radical invasion, and .1 Neovascularization in surgery plus lymphadenectomy surgery or chemora- cervical tumors is indicative of aggressive clinical diation plus brachytherapy if detected early. Unfortu- behavior and poor prognosis.2 nately, for patients with metastatic or recurrent disease, effective therapeutic options are limited for PATHOLOGIC EVIDENCE IN SUPPORT OF this aggressive life-threatening condition. However, ANGIOGENESIS-DRIVEN CERVICAL molecularly targeted agents have provided a critical CARCINOMA opportunity to improve patient outcomes beyond Several key translational studies have reported the optimizing cytotoxic chemotherapy regimens so that association between markers of angiogenesis and they may benefit from other agents or emergent prognosis in cervical cancer. Cooper et al3 assessed

Scan the QR Code with your phone to obtain Accepted for publication November 24, 2014. FREE ACCESS to the articles featured in the http://dx.doi.org/10.1016/j.clinthera.2014.11.012 Clinical Therapeutics topical updates or text 0149-2918/$ - see front matter GS2C65 to 64842. To scan QR Codes your & 2015 Elsevier HS Journals, Inc. All rights reserved. phone must have a QR Code reader installed.

January 2015 9 Clinical Therapeutics intratumoral microvessel density (MVD) in 111 patients lymphatic metastasis.12 Researchers have proposed with locally advanced cervical cancer and found that that CD40 staining is a useful biomarker for evalua- higher tumor vascularity was associated with lower ting the risk of developing cervical malignant tumors overall survival (OS) and locoregional control after and better understanding the immune response against treatment with pelvic irradiation. Similarly, Obermair these tumors and may provide a potential target et al4 reported enhanced 5-year survival with lower for future research in immunotherapy. In addition, MVD (r20 per high-power field) of approximately maspin is another example of a clinicopathologic 90% compared with 63% with higher MVD in 166 biomarker that has been studied and is predictive patients with stage IB cervical cancer; MVD identified with regard to the correlation between tissue patients with early-stage disease with negative nodes at expression of maspin and prognosis in squamous high-risk for relapse. Angiogenesis appears to be an early cell cervical carcinomas. Maspin (a member of the event in premalignant changes of the cervix from high- serine inhibitors) has an inhibitory effect on grade cervical intraepithelial neoplasia, and MVD in- angiogenesis and is thought to be potentially creases significantly with malignant transformation, sug- implicated in lymphangiogenesis in cervical cancer. gesting it is a prerequisite for the development of invasive Liu et al13 found that cytoplasmic and nuclear – cancer.5 7 Other authors have confirmed that cervical expression of maspin is significantly weaker in carcinomas characterized by strong staining for the squamous cell carcinomas compared with high-grade endothelial marker CD31 (immunohistochemistry [IHC] dysplasia and normal cervical specimens. Subcellular marker used to measure degree of tumor angiogenesis) expression of maspin was significantly decreased or and increased MVD are correlated with worse survival.8,9 absent in the presence of high-lymphatic MVD, In contrast to earlier studies, a prospective analysis advanced clinical stage, and lymph node metastases. performed 10 years later examined CD31 MVD in Therefore, given the prominence of vascular aber- patients who received cisplatin-based chemotherapy rations and prognostic significance in cervical cancer, along with adjuvant radiation after radical hysterec- active agents that mediate angiogenesis were expected tomy in high-risk patients. Increased tumor angiogen- to aid in the development of more effective treatments. esis as reflected by CD31 MVD was an independent However, a more thorough molecular characteriza- prognostic factor for improved progression-free sur- tion of cervical cancer remains crucial to the develop- vival (PFS) and OS. This observation was attributed to ment of tolerable and effective biologic therapies. improved delivery of oxygen, nutrients, and cytotoxic chemotherapy to well-vascularized and oxygenated A MOLECULAR CASCADE LINKING VIRAL þ tumors.10 The vasculature associated with CD31 ONCOGENE EXPRESSION AND endothelial cells tends to be more organized and may VEGF-DEPENDENT ANGIOGENESIS result in less tumor hypoxia, whereas , or One frequently studied candidate for biologic thera- CD105 (coreceptor for transforming growth factor-β), pies involves the VEGF signaling pathway because it is þ enriched endothelial cells are disorganized and CD105 one of the major drivers of angiogenesis in cervical MVD is associated with an increased relative risk of cancer. Dobbs et al5 established that VEGF receptor treatment failure.11 Observed differences in survival expression is correlated with MVD in cervical and pathologic tumor features may be related to the carcinomas. In addition, persistent infection with the progression and stages of angiogenesis. oncogenic subtypes of HPV increases angiogenic Investigation of several other pathologic features potential in tumors through upregulation of VEGF. and IHC staining of cervical tumors led to the By all accounts, this is an early event in the stages of description of other potentially clinically relevant carcinogenesis from chronic HPV infection or cervical biomarkers that may be correlated with prognosis intraepithelial neoplasia to invasive cancer.15,25 There and metastatic spread (Table I). For example, there is is a wide range of cellular factors and pathways that evidence that CD40 is overexpressed in cervical have been linked to HPV genomic integration and positive for human papillomavirus (HPV)-16 downstream effects on targets that promote angio- and -18 and is associated with neovascularization via genesis in cervical tumors, thus permitting neovascu- vascular endothelial growth factor (VEGF)–induced larization and enabling tumors to acquire the blood angiogenesis. CD40 expression also correlates with supply required for permissive growth and spread.26

10 Volume 37 Number 1 L.S. Krill and K.S. Tewari

Table I. List of candidate genes and proteins of interest related to angiogenesis and endothelial cell markers as prognostic indicators in cervical carcinoma.

Molecular Target (Gene/Protein/Biomarker) Pathologic and/or Prognostic Significance in ICC

Adrenomedullin Proangiogenic peptide upregulated in ICC, target of miR-126 CD31 Endothelial marker associated with MVD in ICC and prognostic for PFS/OS10 CD40 Endothelial marker overexpressed with HPV-16/18þ ICC, associated with lymphatic metastasis and neovascularization12 CHI3L1 Overexpression of secreted glycoprotein correlates with prognosis and metastasis in ICC14 Colony-stimulating factor Proto-oncogene present in most ICC and absent in normal cervix, receptor stimulates VEGF-mediated angiogenesis, and involved in carcinogenesis15 COX-2 COX-2 inhibition attenuated VEFG-C expression, potent mediator of lymphangiogenesis16 Endoglin (CD105) Angiogenesis marker, highest in peritumoral areas, and correlated with VEGF and EGFR overexpression17 Fibulin-4 Glycoprotein upregulated in ICC, promotes angiogenesis and associated with poor clinicopathologic characteristics18 Maspin Tumor suppressor implicated in lymphangiogenesis and metastasis13 miR-126 Micro-RNA involved in angiogenesis and vascular integrity, downregulated19 Tc17 (cytotoxic T cells and IL-17) Infiltration by IL-17–producing T cells in ICC correlated with lymph node metastasis and MVD20 TSP-1 Antiangiogenesis factor that may regulate the angiogenic switch between CIN and ICC, mixed data on prognostic significance10,21,22 Tissue factor pathway inhibitor Serine protease inhibitor implicated in , angiogenesis, and progression of ICC23 Transforming growth factor-β1 Prognostic marker, strong expression associated with worse survival in þ CD105 tumors11 Vasohibin Angiogenesis inhibitor and potential marker, endothelial cell expression correlated with VEGFR-2 in ICC24

CIN ¼ cervical intraepithelial neoplasia; COX ¼ cyclooxygenase; EGFR ¼ epidermal growth factor receptor; HPV ¼ human papillomavirus; ICC ¼ invasive cervical cancer; IL ¼ interleukin; MVD ¼ microvessel density; OS ¼ overall survival; PFS ¼ progression-free survival; TFPI ¼ tissue factor pathway inhibitor; TSP ¼ ; VEGFR ¼ vascular endothelial growth factor receptor.

HPV-16 and -18 are responsible for the over- maintenance of the immortalized malignant pheno- whelming majority of cervical cancer, and one of the type caused by ongoing infection.27 E6 and E7 code key steps in carcinogenesis involves integration of the for proteins that knock out cellular (host) tumor sup- HPV genome and host DNA. The responsible inter- pressor gene products, leading to several alterations in mediaries, E6 and E7, are the only HPV gene products molecular signaling cascades that ultimately induce that are consistently retained in invasive cervical can- VEGF-dependent angiogenesis. The transcriptional re- cers and are responsible for the transformation and pression of these viral oncogenes by E2, an HPV-related

January 2015 11 Clinical Therapeutics gene product, is disrupted during the process of viral positively regulated by p53 but are decreased in cells integration. Consequently, E6 and E7 are expressed, that express E6 and E7. Conversely, VEGF (angio- permitting transcription of certain oncoproteins that genesis inducer), which is usually negatively regulated interact with other gene products to have 2 important by p53 via the transcription factor hypoxia inducible effects: p53 degradation and pRb inactivation, respec- factor (HIF)-1α, is upregulated.26 In addition, HPV E6 tively. The proangiogenic signals that result from these and E7 independently enhance the induction and molecular signaling changes after integration of high- stabilization of HIF-1α in in vivo models.29 The risk HPV genomes into host cellular chromosomes are oncogenes again have different mechanisms of given in Figure 1. After DNA damage, HPV E6 achieving similar effects. HPV E7 increases HIF-1 proteins block the induction of p53, preventing the transcriptional activity, but E6 counteracts the repres- cell from going into cell cycle arrest to allow DNA sion of HIF-1 through the p53 pathway.30 Further- repair and aborting programmed cell death or more, E7 enhances HIF-1–mediated transcription by apoptosis and thus allowing continued cellular inhibiting binding of histone deacetylases and proliferation. E6 expression can promote ubiquitina- promoting angiogenesis.30 HIF-1α is a transcription tion of p53, leading to rapid proteasomal protein factor that controls the expression of 440 different degradation. In some cases, certain polymor- genes that encode various cytokines and growth phisms bind more ardently with oncogenic HPV factors involved in angiogenesis, including VEGF. E6.2 Individuals with HPV who carry the Arg Induction and stabilization of HIF-1α can be accom- variant (Arg 72) are an example of how this plished by viral oncogenes, as described here, through particular polymorphism increases the likelihood of dysregulation of tumor suppressor genes or invoked progression from cervical intraepithelial neoplasia to by other mechanisms in response to environmental invasive cancer compared with the Pro variant stressors such as hypoxia. As tumors grow beyond (Pro72).28 E7-driven cell cycle progression that results their existing blood supply and decreased oxygen from abrogation of pRb function has the opposite tension is encountered, changes in gene expression effect from E6 by potentiating apoptosis through are triggered which support angiogenesis and may be upregulation of the p53 pathway. The induced independent of the effects of HPV E6 and E7. changes in several angiogenesis mediators that are Both oncogenes have a wide range of other targets that regulated by p53 are differentially affected by the are not completely understood. However, the cumulative expression of E6 and E7. Thromobospondin-1 and results of these modifications in gene transcription, maspin are angiogenesis inhibitors that are normally protein function, and the tumor microenvironment

HPV E6 p53 degradation TSP-1 VEGF Angiogenesis

HPV Anti-VEGF therapy Genome

Displacement of HDAC1, HDAC4, HIF-1α HDAC7 HPV E7 pRb inactivation p21-Rb pathway dysregulation

Abbreviations: HDAC, histone deacetylase; HIF1α, hypoxia-inducible factor 1-alpha; HPV, human papilloma virus; pRb, retinoblastoma protein; TSP1, ; VEGF, vascular endothelial growth factor.

Figure 1. Proposed mechanism of human papillomavirus (HPV) infection and the rationale behind angiogenesis inhibitor therapy. HDAC ¼ histone deacetylase; HIF-1α ¼ hypoxia-inducible factor- 1α; TSP-1 ¼ thrombospondin-1; VEGF ¼ vascular endothelial growth factor.

12 Volume 37 Number 1 L.S. Krill and K.S. Tewari ultimately lead to increased VEGF and increased upregulate proangiogenic factors, such as VEGF, angiogenesis potential. Overexpression of VEGF has platelet derived growth factor, and other small mole- been associated with cancer progression and poor cules, have been correlated with advanced refractory prognosis in many malignant tumors, including cer- disease and poor survival but also present exciting vical carcinoma. Therefore, the rationale for antian- opportunities for the development of therapeutic giogenesis therapy in cervical cancer stems from the interventions. association of VEGF, pathologic neovascularization, and the development of invasive disease. CLINICAL RAMIFICATIONS OF However, other molecular alterations contribute to ANGIOGENESIS INHIBITION IN ADVANCED the progression of cervical carcinogenesis beyond DISEASE HPV infection alone because only a small proportion This body of translational work has established bio- of these cases will progress to invasive cancer. Other logical plausibility to justify the investigation of genetic and environmental factors must play an impor- angiogenesis inhibitors in cervical cancer on both a tant role in the balance between activating oncogenes molecular level and a clinicopathologic basis. VEGF- and inhibiting the function of tumor suppressor genes. mediated angiogenesis is so critical to carcinogenesis For example, researchers have been able to characterize in cervical cancer it follows therefore that disruption several polymorphisms within the VEGF gene that not of this pathway with molecularly targeted agents may only affect angiogenesis but also influence survival and be useful in retarding tumor growth, progression, and susceptibility to cervical cancer. This study compared 4 metastasis or perhaps even eliminating small volume different VEGF genetic polymorphisms in the promoter residual disease. Furthermore, antiangiogenesis agents region that could affect VEGF protein production or are efficacious in other solid malignant tumors with function (2578C4A, 460 T4C, þ405 G4C, and similar tumor biology, such as non–small cell lung þ936 C4T) in 215 patients without cervical cancer and cancer. Bevacizumab is the most studied agent in 199 patients with cervical cancer who underwent sur- gynecologic and other solid tumors. gery.31 The VEGF 2578 C4A genotype was Bevacizumab is an anti-VEGF monoclonal anti- associated with a decreased risk of cervical cancer body that blocks tumor angiogenesis by binding and (adjusted odds ratio ¼ 0.39; 95% CI, 0.16–0.96). inactivating VEGF and thereby inhibiting endothelial CD31 MVD was used as a marker for angiogenesis cell activation and proliferation, thus denying tumors and was significantly decreased in patients with the the ability to recruit new vessel development. Bevaci- VEGF þ405C/C genotype. In addition, decreased zumab also counteracts the survival (antiapoptotic) CD31 MVD was an independent risk factor for disease signaling that supports the immature vasculature recurrence, and CD31 MVD was significantly associated usually associated with neoplastic growth and pre- with disease-free survival (adjusted hazard ratio [HR] ¼ vents constant endothelial remodeling required for 0.23; 95% CI, 0.06–0.92). After controlling for other local tumor spread, thus restoring normal structure clinical prognostic factors, such as stage, tumor size, and function to disorganized, highly permeable vessels depth of invasion, lymphovascular space invasion, and typically seen in malignant tumors.32 It is currently adjuvant treatment, VEGF þ405 G4C played a detri- approved by the US Food and Administration mental role in patients with cervical cancer based on Cox (FDA) for use in the management of non–small cell regression analysis. The VEGF þ405C/C and VEGF lung cancer, renal cell carcinoma, colorectal cancer, 2578C, 460 T, þ405C haplotypes were significantly and, most recently, recurrent cervical cancer. related to shorter disease-free survival (adjusted HR ¼ On the basis of the available literature, the use of 3.18; 95% CI, 1.13–8.94) and OS (adjusted HR¼ 8.86; cisplatin-based combination chemotherapy has been 95% CI, 1.40–56.08). These findings suggest that genetic widely adopted as the standard treatment backbone in polymorphisms are capable of modulating angiogenesis cervical cancer. Unfortunately, responses to chemo- in tumors and thus may affect response to treatment and therapy are usually temporary, with median durations survival in early cervical cancers. typically lasting 3 to 6 months.33 More than 90% of In summary, translational investigations have the deaths attributed to cervical carcinoma occur found that proangiogenic signaling cascades are active within 5 years after diagnosis. Chemotherapy for in cervical carcinogenesis. Molecular alterations that recurrence is essentially palliative because effective

January 2015 13 Clinical Therapeutics salvage therapies are lacking. This finding under- patients were randomized to receive carboplatin scores the need for more effective treatment strate- (AUC ¼ 5) and paclitaxel (175 mg/m2) every 21 days gies for this clinical scenario. To improve the current plus either 20 mg of cediranib or a placebo daily.37 management paradigm, researchers have developed The results revealed a statistically significant therapeutic strategies that incorporate biologic agents improvement in median PFS with chemotherapy plus with standard treatments. In a small case series, cediranib compared with placebo (35 vs 30 weeks; bevacizumab exhibited activity in patients with HR ¼ 0.61; 80% CI, 0.41–0.89; P ¼ 0.046). The recurrent cervical carcinoma when combined with median change in serum VEGF inhibition was also cytotoxic chemotherapy.34 significantly improved with cediranib, and toxic The first prospective Phase II trial of bevacizumab effects appeared on par with other similar biologic in cervical cancer was conducted through the cooper- agents. Overall, on the basis of reported results, ative research network led by the Gynecologic Oncol- cediranib appears tolerable and active in advanced ogy Group (GOG). GOG 227C was a multicenter cervical cancer. The study was not intended or Phase II study of bevacizumab monotherapy that powered to assess OS, but further investigation with revealed the tolerability and efficacy of the drug in a larger Phase III trial is warranted. Table II provides heavily pretreated patients with recurrent cervical a summary of 3 prospective Phase II clinical trials that cancer—bevacizumab performed even better than feature VEGF-based therapies in advanced or recur- expected particularly compared with other historical rent cervical cancer. control groups in this setting.35 Subsequently, other The first Phase III randomized clinical trial of agents with antiangiogenic activity have also been antiangiogenesis therapy in cervical cancer was ini- studied in advanced and recurrent cervical cancer, tiated by the GOG and cosponsored by the National including oral tyrosine kinase inhibitors. Cancer Institute to study the combination therapy of (targets VEGF receptor, platelet-derived growth factor bevacizumab and standard cytotoxic chemotherapy in receptor, and c-kit) and lapatinib (dual anti–epidermal patients with recurrent, persistent, or metastatic cer- growth factor receptor and anti-HER2/neu) were vical cancer. GOG 240 was designed to address 2 studied in a Phase II trial comparing pazopanib (800 critical issues in this setting—the effectiveness of mg/d) or lapatinib (1,500 mg/d) monotherapy versus antiangiogenesis therapy and the effectiveness of combination therapy with both ; however, the nonplatinum-based chemotherapy doublets. A 2 2 combination therapy treatment arm was closed for factorial design was used to answer the biologic/ futility and imbalanced toxic effects after the first antivascular hypothesis and the chemotherapy ques- interim analysis.36 This head-to-head comparison tion of whether a nonplatinum doublet would have revealed the superiority of antiangiogenesis over greater activity in the recurrent disease population. anti-EGF therapy. Pazopanib improved PFS compared This was an important question because of the with lapatinib (4.5 vs 4.3 months; HR ¼ 0.66; 90% concern for possible platinum drug resistance given CI, 0.48–0.91; P o 0.013) but did not result in an OS the widespread adoption of platinum-based chemo- benefit (12.4 vs 11 months; HR ¼ 0.67; 90% CI, radiation in the primary treatment of locally advanced 0.46–0.99; P ¼ 0.045). The study provides additional cancer with 470% of the patients in each group support for pursuing further investigations of anti- having had prior exposure to cisplatin. VEGF treatments in cervical cancer, but unfortunately Consequently, patients were randomized to receive epidermal growth factor receptor–based therapies, 1 of 4 regimens: cisplatin (50 mg/m2) plus paclitaxel such as cetuximab and erlotinib, have resulted in (135 or 175 mg/m2) with or without bevacizumab (15 several negative clinical trials (data not shown). mg/kg) or topotecan (0.75 mg/m2 on days 1 through The newest Phase II study of another angiogenesis 3) plus paclitaxel (175 mg/m2) with or without inhibitor was recently presented at the annual meeting bevacizumab (15 mg/kg) with cycles repeated every of the European Society for Medical Oncology in 21 days until disease progression or unacceptable September, 2014. Cediranib is a once-daily oral toxic effects occurred. The results confirmed that tyrosine kinase inhibitor that was used in combination the topotecan/paclitaxel chemotherapy doublet was with a conventional chemotherapy in patients with not superior to cisplatin/paclitaxel (median OS of metastatic or recurrent cervical cancer. Sixty-nine 12.5 vs 15 months; HR ¼ 1.20; 99% CI, 0.82–1.76;

14 Volume 37 Number 1 aur 2015 January

Table II. Phase II studies of VEGF-based therapies in metastatic or recurrent cervical malignant tumors.

Response PFS, Median (Range) OS, Median Study Design Rate (Range) Toxic Effects

GOG 227C35 Bevacizumab PR ¼ 10.9% 3.4 mo (2.5–4.5 mo) 7.3 mo (6.1–10.4 mo) Common grade 3/4 AEs: HTN (n ¼ 7), VTE monotherapy 15 mg/ (n ¼ 5), and GI (n ¼ 4); grade 5 infection kg q21d (n ¼ 46) (n ¼ 1) PFS Z6mo¼ 23.9% VEG10528136 Pazopanib Arm P ¼ 9% 18.1 wk (4.5 mo) 50.7 wk (12.7 mo) Common AEs: diarrhea (54% vs 58%; grade 3 monotherapy 800 mg ¼ 11% vs 13%); nausea (36% vs 33%), HTN once daily (30% vs 3%), anorexia (28% vs 32%), any (arm P; n ¼ 74) grade 4 (12% v 9%) for arm Lapatinib monotherapy Arm L ¼ 5% 17.1 wk (4.3 mo) 39.1 wk (9.8 mo) PvsarmL 1500 mg once daily (arm L; n ¼ 78) Combination therapy HR ¼ 0.66 (95% CI, HR ¼ 0.67 (95% CI, (discontinued for 0.48–0.91) 0.46–0.99) futility and unacceptable toxic effects) CIRCCa37 Carboplatin/paclitaxel Arm C ¼ 66% 35 wk (8.8 mo) 59 wk (14.8 mo) Grade 2 to 4 AEs: diarrhea (50% vs 18%), and cediranib 20 mg/ HTN (34% vs 12%), any grade (19% vs 9%) d (arm C; for arm C vs arm Z n ¼ 34)

Carboplatin/paclitaxel Arm Z ¼ 42% 30 wk (7.5 mo) 63 wk (15.8 mo) Tewari K.S. and Krill L.S. and placebo (arm Z; HR ¼ 0.61 (95% CI, HR ¼ 0.93 (95% CI, n ¼ 35) 0.41–0.89) 0.64–1.36)

AE ¼ adverse event; CIRRCa ¼ cediranib for advanced cervical cancer; GI ¼ gastrointestinal; GOG, Gynecologic Oncology Group; HR ¼ hazard ratio; HTN ¼ hypertension; OS ¼ overall survival; PFS ¼ progression-free survival; PR ¼ partial response; VEGF ¼ vascular endothelial growth factor; VTE ¼ venous thromboembolism. 15 Clinical Therapeutics

Chemotherapy Chemotherapy + (n = 225) Bev (n = 227)

1.0 Events, n (%) 140 (62) 131 (58) Median OS, 13.3 17.0 0.9 months 0.8 HR=0.71 (97% Cl, 0.54–0.94) = 0.7 P 0.0035 0.6 Median follow-up 20.8 months 0.5 0.4 0.3 Proportion Surviving 0.2 0.1 0.0 01224 36 Months on Study Figure 2. Gynecologic Oncology Group 240 results: overall survival curve. HR ¼ hazard ratio; OS ¼ overall survival. Copyright Massachusetts Medical Society. Adapted with permission from the New England Journal of Medicine.28

P ¼ 0.88).38 The final analysis revealed superior As with any other experimental regimens, the outcomes when bevacizumab was added to either benefits must outweigh the risks of treatment. Bev- chemotherapy regimen, leading to an HR for death acizumab was associated with a reasonable toxicity of 0.71 (97.6% CI, 0.54–0.94; P ¼ 0.0035). The profile that is similar to previous studies with this survival curves are given in Figure 2. The median OS drug. The overall rate of serious adverse effects for patients who received cisplatin plus paclitaxel was associated with bevacizumab-containing regimens 14.3 months, significantly less than the 17.5 months was o10% in GOG 240. As expected from previous for those who received cisplatin, paclitaxel, and reports, treatment-related toxic effects observed with bevacizumab (P ¼ 0.0348). In parallel, the median the incorporation of bevacizumab included mainly OS for those who received topotecan plus paclitaxel thromboembolism (8%) gastrointestinal or genitouri- was lower compared with when bevacizumab was nary fistulas (6%), and hypertension (25%). No new added to that regimen (12.7 months compared with toxic effects of bevacizumab were identified, and no 16.2 months respectively; P ¼ 0.09). GOG 240 is a deterioration in health-related quality of life was landmark trial because it is the first time that a reported by patients receiving bevacizumab.38 After targeted agent has reached its primary end point of GOG 240 it is critical that all health care professionals improving OS in a gynecologic malignant tumor. and patients are educated about these findings to Bevacizumab was also established as a triple-threat ensure that all women with persistent, recurrent, or after publication of GOG 240. In addition to achiev- metastatic cervical cancer who may benefit from ing the clinical benefit gold standard in oncology trials bevacizumab are appropriately counseled about the (prolonged OS), patients who received bevacizumab risks and benefits of adding bevacizumab to standard also had improved PFS (HR ¼ 0.67; 95% CI, 0.54– chemotherapy. Individual treatment decisions should 0.82; P ¼ 0.0002) and higher response rates than be made on a case-to-case basis and take into account controls (48% vs 36%; P ¼ 0.008). Twenty-eight prior treatment history, medical comorbidity, func- patients who received bevacizumab had complete tional status, predisposition to certain toxic effects, responses compared with 14 in the control groups. and quality of life. Appropriate patient selection, close Even patients with disease contained within a previ- clinical monitoring, and cautious attention to the ously irradiated pelvis experienced sustained clinical management of treatment-related adverse effects will benefit from bevacizumab.38 optimize efficacy and tolerability.

16 Volume 37 Number 1 L.S. Krill and K.S. Tewari

The National Cancer Institute issued a practice increasing demand for second- and third-line therapies changing press release after the initial results from moving forward, resulting in an unmet clinical need GOG 240 were presented at the American Society of for alternative agents and new treatment paradigms Clinical Oncology annual meeting in June 2013 in for this disease in the future. Molecularly targeted support of bevacizumab for late-stage cervical drugs are needed to exploit other relevant signal cancer.39 In July 2013, the National Comprehensive transductions pathways to disrupt the highly inte- Cancer Network updated their practice guidelines for grated tumor microenvironment, and cervical cancer treatment to include the cisplatin- modulation will be critical to achieving improved paclitaxel-bevacizumab triplet as Category 2A (and oncologic outcomes for women affected by invasive would ultimately list both triplet regimens as Category cervical cancer. 1 in August 2014).40 Attaining expeditious FDA approval was a crucial step in enhancing the care of ACKNOWLEDGMENTS women with invasive cervical cancer because this The entire manuscript was completely written by regulatory milestone is required for coverage under Dr. Lauren Krill, reviewed and edited by Dr. Tewari, Medicare and Medicaid. In less than 4 months after and developed into its final form by both Dr Krill and filing under the FDA’s priority review program, in Dr. Tewari. No outside writers were used. August 2014 bevacizumab became the first biologic agent approved for use in patients with late stage cervical cancer and was the first drug approved in this CONFLICTS OF INTEREST patient population since 2006.41 This overwhelming Dr Tewari has reported working as a consultant for and rapid response is a reflection of the importance Roche/Genentech, Caris, and Advaxis; serving on the of successfully addressing a historically unfulfilled advisory board of Roche/Genentech, Caris, Advaxis, clinical need. Vermillion; serving on the speaker's bureau of Ver- million; and performing contracted research for Gen- FUTURE DIRECTIONS entech, Amgen, Endocyte, and Astra-Zeneca. The The excitement created with publication of GOG 240 authors have indicated that they have no other will promote the continued study of other classes of conflicts of interest regarding the content of this antiangiogenesis inhibitors in recurrent or even front- article. line therapy for cervical cancer. The observed bene- fi ts associated with several antiangiogenesis agents in REFERENCES the aforementioned Phase II and Phase III trials merit 1. Kerbel RS. Tumor angiogenesis. N Engl J Med. 2008;358: additional investigation to further refine the most 2039–2049. appropriate regimen for this population with toler- 2. Tewari KS, Monk BJ. New strategies in cervical cancer: fi able toxic effects. Moving forward, con rmatory from angiogenesis blockade to immunotherapy. Clin Phase III clinical trial proposals should include multi- Cancer Res. 2014;20:5349–5358. factorial study designs that combine conventional 3. Cooper RA, Wilks DP, Logue JP, et al. High tumor chemotherapy backbones with known active angiogenesis is associated with poorer survival in carci- biologic agents, including carboplatin or cisplatin/ noma of the cervix treated with radiotherapy. Clin Cancer paclitaxel/bevacizumab with or without cediranib or Res. 1998;4:2795–2800. pazopanib. 4. Obermair A, Wanner C, Bilgi S, et al. Tumor angiogenesis in Unfortunately, despite the proven efficacy of anti- stage IB cervical cancer: correlation of microvessel density – angiogenesis therapy in cervical cancer, disease recur- with survival. Am J Obstet Gynecol. 1998;178:314 319. 5. Dobbs SP, Hewett PW, Johnson IR, et al. Angiogenesis is rence is still problematic for these women. Most associated with vascular endothelial growth factor expres- patients diagnosed as having locally advanced or sion in cervical intraepithelial neoplasia. Br J Cancer. metastatic cervical cancer will experience disease 1997;76:1410–1415. recurrence. Historically, this disease is often refractory 6. Dellas A, Moch H, Schultheiss E, et al. Angiogenesis in to chemotherapy, resulting in disappointing responses cervical neoplasia: microvessel quantitation in precancer- to salvage therapies. However, if patients are living ous lesions and invasive carcinomas with clinicopatho- longer with antiangiogenesis therapy, there will be an logical correlations. Gynecol Oncol. 1997;67:27–33.

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7. Tjalma W, Sonnemans H, Weyler J, lymphangiogenesis and lymph oncoproteins in primary foreskin et al. Angiogenesis in cervical intra- node metastasis in human cervical keratinocytes is sufficient to alter epithelial neoplasia and the risk of cancer. Microvasc Res. 2011;82:131– the expression of angiogenic factors. recurrence. Am J Obstet Gynecol. 140. Oncogene. 2004;23:2988–2995. 1999;181:554–559. 17. Barbu I, Craitoiu S, Simionescu CE, 27. Baker CC, Phelps WC, Lindgren V, 8. Wiggins DL, Granai CO, Steinhoff et al. CD105 microvessels density, et al. Structural and transcriptional MM, Calabresi P. Tumor angiogen- VEGF, EGFR-1 and c-erbB-2 and analysis of human papillomavirus esis as a prognostic factor in cervical their prognostic correlation in differ- type 16 sequences in cervical carci- carcinoma. Gynecol Oncol. 1995;56: ent subtypes of cervical adenocarci- noma cell lines. J Virol. 1987;61:962– 353–356. noma. Rom J Morphol Embryol. 971. 9. Sharma B, Singh N, Gupta N, et al. 2013;54:519–530. 28. Habbous S, Pang V, Eng L, et al. p53 Diagnostic modalities of precancer- 18. Chen J, Zhang J, Liu X, et al. Over- Arg72Pro polymorphism, HPV status ous and cancerous cervical lesions expression of fibulin-4 is associated and initiation, progression, and de- with special emphasis on CD31 with tumor progression and poor prog- velopment of cervical cancer: a sys- angiogenesis factor as a marker. nosis in patients with cervical carci- tematic review and meta-analysis. Patholog Res Int. 2013;2013:243168. noma. Oncol Rep. 2014;31:2601–2610. Clin Cancer Res. 2012;18:6407–6415. 10. Randall LM, Monk BJ, Darcy KM, 19. Huang TH, Chu TY. Repression of 29. Nakamura M, Bodily JM, Beglin M, et al. Markers of angiogenesis in miR-126 and upregulation of adreno- et al. Hypoxia-specific stabilization high-risk, early-stage cervical cancer: medullin in the stromal of HIF-1α by human papillomavi- a Gynecologic Oncology Group by cancer-stromal cross talks confers ruses. Virology. 2009;387:442–448. study. Gynecol Oncol. 2009;112:583– angiogenesis of cervical cancer. 30. Bodily JM, Mehta KP, Laimins LA. 589. Oncogene. 2014;33:3636–3647. Human papillomavirus E7 enhances 11. Lin H, Huang CC, Ou YC, et al. High 20. Zhang Y, Hou F, Liu X, et al. Tc17 hypoxia-inducible factor 1-mediated immunohistochemical expression of cells in patients with uterine cervical transcription by inhibiting binding TGF-beta1 predicts a poor prognosis cancer. PloS ONE. 2014;9:e86812. of histone deacetylases. Cancer Res. in cervical cancer patients who 21. Wu MP, Tzeng CC, Wu LW, et al. 2011;71:1187–1195. harbor enriched endoglin microvessel Thrombospondin-1 acts as a fence 31. Kim YH, Kim MA, Park IA, et al. density. Int J Gynecol Pathol. 2012;31: to inhibit angiogenesis that occurs VEGF polymorphisms in early cervi- 482–489. during cervical carcinogenesis. cal cancer susceptibility, angiogene- 12. Huang Q, Qu QX, Xie F, et al. CD40 Cancer J. 2004;10:27–32. sis, and survival. Gynecol Oncol.2010; is overexpressed by HPV16/18-E6 22. Kodama J, Hashimoto I, Seki N, 119:232–236. positive cervical carcinoma and cor- et al. Thrombospondin-1 and -2 32. Monk BJ, Willmott LJ, Sumner DA. related with clinical parameters and messenger RNA expression in inva- Anti-angiogenesis agents in meta- vascular density. Cancer Epidemiology. sive cervical cancer: correlation with static or recurrent cervical cancer. 2011;35:388–392. angiogenesis and prognosis. Clin Gynecol Oncol. 2010;116:181–186. 13. Liu Z, Shi Y, Meng W, et al. Expression Cancer Res. 2001;7:2826–2831. 33. Eskander RN, Tewari KS. Chemo- and localization of maspin in cervical 23. Zhang Q, Zhang Y, Wang SZ, et al. therapy in the treatment of meta- cancer and its role in tumor progres- Reduced expression of tissue factor static, persistent, and recurrent sion and lymphangiogenesis. Arch pathway inhibitor-2 contributes to cervical cancer. Curr Opin Obstet Gynecol Obstet. 2014;289:373–382. apoptosis and angiogenesis in cer- Gynecol. 2014;26:314–321. 14. Ngernyuang N, Francescone RA, vical cancer. J Exp Clin Cancer Res. 34. Wright JD, Viviano D, Powell MA, Jearanaikoon P, et al. Chitinase 3 2012;31:1. et al. Bevacizumab combination like 1 is associated with tumor 24. Yoshinaga K, Ito K, Moriya T, et al. therapy in heavily pretreated, recur- angiogenesis in cervical cancer. Int J Roles of intrinsic angiogenesis inhib- rent cervical cancer. Gynecol Oncol. Biochem Cell Biol. 2014;51:45–52. itor, vasohibin, in cervical carcino- 2006;103:489–493. 15. Hammes LS, Tekmal RR, Naud P, mas. Cancer Sci. 2011;102:446–451. 35. Monk BJ, Sill MW, Burger RA, et al. et al. Up-regulation of VEGF, c-fms 25. Di Saia PJ, Di Saia PJ, Creasman Phase II trial of bevacizumab in the and COX-2 expression correlates with WT, Di Saia PJ. Clinical Gynecologic treatment of persistent or recurrent severity of cervical cancer precursor Oncology. 8th ed. Philadelphia, PA: squamous cell carcinoma of the cervix: (CIN) lesions and invasive disease. Elsevier/Saunders; 2012. a Gynecologic Oncology Group study. Gynecol Oncol. 2008;110:445–451. 26. Toussaint-Smith E, Donner DB, JClinOncol. 2009;27:1069–1074. 16. Liu H, Xiao J, Yang Y, et al. COX-2 Roman A. Expression of human 36. Monk BJ, Mas Lopez L, Zarba JJ, expression is correlated with VEGF-C, papillomavirus type 16 E6 and E7 et al. Phase II, open-label study of

18 Volume 37 Number 1 L.S. Krill and K.S. Tewari

pazopanib or lapatinib monother- apy compared with pazopanib plus lapatinib combination therapy in patients with advanced and recur- rent cervical cancer. J Clin Oncol. 2010;28:3562–3569. 37. Symonds P, Gourley C, Davidson S, et al. LBA25_PR-CIRCCa: A rando- mised double blind phase II trial of carboplatin-paclitaxel plus cediranib versus carboplatin-paclitaxel plus placebo in metastatic/recurrent cer- vical cancer. ESMO Abstract 2014. 38. Tewari KS, Sill MW, Long HJ 3rd, et al. Improved survival with bevaci- zumab in advanced cervical cancer. N Engl J Med. 2014;370:734–743. 39. Bevacizumab significantly improves survival for patients with recurrent and metastatic cervical cancer [NCI press release]. www.cancer.gov/news center/newsfromnci/2013/GOG240. Accessed December 19, 2014. 40. NCCN Clinical Practice Guidelines in Oncology. Cervical Cancer Ver- sion 2. 2015. 41. FDA approves Avastin to treat pa- tients with aggressive and late-stage cervical cancer. http://www.fda.gov/ NewsEvents/Newsroom/PressAnnou ncements/ucm410121.htm. Accessed December 19, 2014.

Address correspondence to: Krishnansu S. Tewari, MD, FACOG, FACS, Division of Gynecologic Oncology, Department of Obstetrics and Gyne- cology, The Chao Family Comprehensive Cancer Center, University of California Irvine Medical Center, 101 The City Drive South, Building 56 Room 264, Orange, CA 92868. E-mail: [email protected]

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