Cervical Cancer: Avastin Efficacy Data


Avastin® (bevacizumab) is the first biologic regimen to demonstrate overall survival (OS) benefit vs chemotherapy alone in persistent, recurrent, or metastatic cervical cancer (CC). [1]

Avastin plus chemotherapy demonstrated statistically significant OS vs chemotherapy alone in CC in the GOG 240 study [1]

GOG 240 study: OS results in CC patients

  • 3.9-month increase in median OS: 16.8 months with Avastin plus chemotherapy vs 12.9 months with chemotherapy alone [1]
    • Hazard ratio (HR)=0.74 (95% confidence interval [CI], 0.58–0.94); P=0.0132 [1]
Avastin GOG 240 Clinical Study Overall Survival Results in Cervical Cancer Patients

Chemotherapy included either cisplatin/paclitaxel or topotecan/paclitaxel.
GOG=Gynecologic Oncology Group.

GOG 240 study: Efficacy data overview [1]

Endpoint

 

Avastin + chemotherapy

Chemotherapy alone

HR
(95% CI)

Pvalue

 

Number of
patients

227

225

 

 

Primary

OS
(median)

16.8 months

12.9 months

0.74
(0.58–0.94)

0.0132

Secondary

ORR

45%
(95% CI, 39–52)

34%
(95% CI, 28–40)

 

Chemotherapy included either cisplatin/paclitaxel or topotecan/paclitaxel.
ORR=overall response rate.

Avastin plus chemotherapy demonstrated increases in OS and ORR [1]:

  • A 30% increase in median OS vs chemotherapy alone (16.8 vs 12.9 months)
  • A 26% reduction in the risk of death vs chemotherapy alone

The GOG 240 study evaluated Avastin plus chemotherapy vs chemotherapy alone for CC [1,3,45] 

Avastin GOG 240 Study Avastin with Chemotherapy Versus Chemotherapy Alone for Cervical Cancer Results Chart
  • The GOG 240 study was a randomized, active-controlled, multicenter study conducted in the US and Spain through the Gynecologic Oncology Group (GOG) and the Spanish Research Group for Ovarian Cancer, and was sponsored by the National Cancer Institute
  • Primary endpoint of the GOG 240 study was OS, with secondary endpoint ORR

The GOG 240 study included a diverse population of women with CC [1,3]
 

Patient characteristics

All patients randomized
at baseline
(N=452)

Median age (range)

48 years (20–85)

Race

Caucasian

Non-Caucasian

 

78%

22%

Prior radiation

80%

Prior chemotherapy concurrent with radiation

74%

Platinum-free interval <6 months

32%

GOG performance status

0

1

 

58%

42%

Demographic and disease characteristics were balanced across arms

Chemotherapy included either cisplatin/paclitaxel or topotecan/paclitaxel. 

Boxed WARNINGS

  • Gastrointestinal (GI) perforation
    • Serious and sometimes fatal GI perforation occurs at a higher incidence (up to 3.2%) in Avastin-treated patients compared to controls. Discontinue Avastin for GI perforation
  • Surgery and wound healing complications
    • The incidence of wound healing and surgical complications, including serious and fatal complications, is increased in Avastin-treated patients 
    • Discontinue in patients with wound dehiscence. Discontinue at least 28 days prior to elective surgery. The appropriate interval between termination of Avastin and subsequent elective surgery required to reduce the risks of impaired wound healing/wound dehiscence has not been determined
    • Do not initiate Avastin for at least 28 days after surgery and until the surgical wound is fully healed
  • Hemorrhage
    • Severe or fatal hemorrhage, hemoptysis, GI bleeding, CNS hemorrhage, epistaxis, and vaginal bleeding are increased in Avastin-treated patients. Do not administer Avastin to patients with serious hemorrhage or recent hemoptysis

OS results by chemotherapy regimen (platinum doublet vs nonplatinum doublet), were also evaluated in the GOG 240 study, regardless of combination with Avastin [1,3,45] 

Chemotherapy analysis of the GOG 240 study: platinum doublet vs nonplatinum doublet [1]

 

Topotecan/paclitaxel
+/- Avastin
(n=223)

Cisplatin/paclitaxel
+/- Avastin
(n=229)

Median OS (months)

13.3

15.5

Hazard ratio

1.15 (95% CI, 0.91–1.46)
P=0.23

  • HR for OS with Avastin plus cisplatin/paclitaxel vs cisplatin/paclitaxel alone was 0.72 (95% CI, 0.51–1.02)
  • HR for OS with Avastin plus topotecan/paclitaxel vs topotecan/paclitaxel alone was 0.76 (95% CI, 0.55–1.06)

Indications

Persistent, recurrent, or metastatic cervical cancer (CC)
Avastin in combination with paclitaxel and cisplatin or paclitaxel and topotecan is indicated for the treatment of persistent, recurrent, or metastatic carcinoma of the cervix.

Boxed WARNINGS

  • Gastrointestinal (GI) perforation
    • Serious and sometimes fatal GI perforation occurs at a higher incidence in Avastin-treated patients compared to controls
    • The incidences of GI perforation ranged from 0.3% to 3.2% across clinical studies
    • Discontinue Avastin in patients with GI perforation
  • Surgery and wound healing complications
    • The incidence of wound healing and surgical complications, including serious and fatal complications, is increased in Avastin-treated patients
    • Do not initiate Avastin for at least 28 days after surgery and until the surgical wound is fully healed. The appropriate interval between termination of Avastin and subsequent elective surgery required to reduce the risks of impaired wound healing/wound dehiscence has not been determined
    • Discontinue Avastin at least 28 days prior to elective surgery and in patients with wound healing complications requiring medical intervention
  • Hemorrhage
    • Severe or fatal hemorrhage, including hemoptysis, GI bleeding, hematemesis, central nervous system hemorrhage, epistaxis, and vaginal bleeding, occurred up to 5-fold more frequently in patients receiving Avastin. Across indications, the incidence of grade ≥3 hemorrhagic events among patients receiving Avastin ranged from 0.4% to 6.9% 
    • Do not administer Avastin to patients with serious hemorrhage or recent hemoptysis (≥1/2 tsp of red blood) 
    • Discontinue Avastin in patients with serious hemorrhage (ie, requiring medical intervention)

Additional serious adverse events

  • Additional serious and sometimes fatal adverse events with increased incidence in the Avastin-treated arm vs control included
    • GI fistulae (up to 2% in metastatic colorectal cancer and ovarian cancer patients)
    • Non-GI fistulae (<1% in trials across various indications; 1.8% in a cervical cancer trial) 
    • Arterial thromboembolic events (grade ≥3, 2.6%)
    • Proteinuria (nephrotic syndrome, <1%)
  • Additional serious adverse events with increased incidence in the Avastin-treated arm vs control included 
    • GI-vaginal fistulae occurred in 8.3% of patients in a cervical cancer trial
    • Venous thromboembolism (grade 3–4, up to 10.6%) in patients with persistent, recurrent, or metastatic cervical cancer treated with Avastin
    • Hypertension (grade 3–4, 5%–18%)
    • Posterior reversible encephalopathy syndrome (PRES) (<0.5%)
  • Infusion reactions with the first dose of Avastin were uncommon (<3%), and severe reactions occurred in 0.2% of patients
  • Inform females of reproductive potential of the risk of ovarian failure prior to starting treatment with Avastin

Pregnancy warning

  • Based on the mechanism of action and animal studies, Avastin may cause fetal harm
  • Advise female patients that Avastin may cause fetal harm, and to inform their healthcare provider of a known or suspected pregnancy 
  • Advise females of reproductive potential to use effective contraception during treatment with Avastin and for 6 months after the last dose of Avastin
  • Advise nursing women that breastfeeding is not recommended during treatment with Avastin
  • Avastin may impair fertility

Most common adverse events

  • Across indications, the most common adverse reactions observed in Avastin patients at a rate >10% and at least twice the control arm rate were

— Epistaxis
— Headache
— Hypertension
— Rhinitis

— Proteinuria
— Taste alteration
— Dry skin
— Rectal hemorrhage

— Lacrimation disorder
— Back pain
— Exfoliative dermatitis

  • Across all studies, Avastin was discontinued in 8.4% to 21% of patients because of adverse reactions

Indication-specific adverse events

  • In CC, grade 3 or 4 adverse reactions in Study GOG 240, occurring at a higher incidence (≥2%) in 218 patients receiving chemotherapy plus Avastin compared to 222 patients receiving chemotherapy alone, were abdominal pain (11.9% vs 9.9%), diarrhea (5.5% vs 2.7%), anal fistula (3.7% vs 0%), proctalgia (2.8% vs 0%), urinary tract infection (8.3% vs 6.3%), cellulitis (3.2% vs 0.5%), fatigue (14.2% vs 9.9%), hypertension (11.5% vs 0.5%), thrombosis (8.3% vs 2.7%), hypokalemia (7.3% vs 4.5%), hyponatremia (3.7% vs 1.4%), dehydration (4.1% vs 0.5%), neutropenia (7.8% vs 4.1%), lymphopenia (6.0% vs 3.2%), back pain (5.5% vs 3.2%), and pelvic pain (5.5% vs 1.4%). There were no grade 5 adverse reactions occurring at a higher incidence (≥2%) in patients receiving chemotherapy plus Avastin compared to patients receiving chemotherapy alone

You may report side effects to the FDA at (800) FDA-1088 or www.fda.gov/medwatch.
You may also report side effects to Genentech at (888) 835-2555.

Please see full Prescribing Information, including Boxed WARNINGS, for additional important safety information.