Ovarian Cancer Treatment – The Latest and Greatest
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Transcript of Ovarian Cancer Treatment – The Latest and Greatest
John K. ChanJohn K. Chan
Gynecologic Cancers
Ovarian Cancer Treatment – Ovarian Cancer Treatment –
The Latest and GreatestThe Latest and Greatest
John K. Chan, M.D.John K. Chan, M.D.Division of Gynecologic OncologyDivision of Gynecologic Oncology
UCSF University School of MedicineUCSF University School of Medicine
John K. ChanJohn K. Chan
Gynecologic Cancers
No relevant financial disclosuresNo relevant financial disclosures
John K. ChanJohn K. Chan
Gynecologic Cancers
OverviewOverview
• Ovarian cancerOvarian cancer– Awareness – symptoms?Awareness – symptoms?– Screening – blood test or ultrasound?Screening – blood test or ultrasound?– Treatment / prevention – surgery and chemotherapyTreatment / prevention – surgery and chemotherapy– Personalized novel therapy – are we there yet?Personalized novel therapy – are we there yet?
• Endometrial cancerEndometrial cancer– Robotic surgery – Man vs. machine?Robotic surgery – Man vs. machine?
John K. ChanJohn K. Chan
Gynecologic Cancers
Ovarian CancerOvarian Cancer
John K. ChanJohn K. Chan
Gynecologic Cancers
Ovarian Cancer – clinical presentationOvarian Cancer – clinical presentation
John K. ChanJohn K. Chan
Gynecologic Cancers
Ovarian - benignOvarian - benign
fibromafibroma
cystadenomacystadenomateratomateratoma
John K. ChanJohn K. Chan
Gynecologic Cancers
Ovarian mucinous cystadenomaOvarian mucinous cystadenoma
John K. ChanJohn K. Chan
Gynecologic Cancers
Ovarian carcinomaOvarian carcinoma
John K. ChanJohn K. Chan
Gynecologic Cancers
Symptoms of “silent killer”Symptoms of “silent killer”
72% of women had 72% of women had recurring symptoms - recurring symptoms - median of 2: median of 2:
• Back pain (45%)Back pain (45%)• Fatigue (34%)Fatigue (34%)• Bloating (27%)Bloating (27%)• Constipation (24%)Constipation (24%)• Urinary symptoms (16%)Urinary symptoms (16%)
Goff et al, JAMA 2004
Early stage (high risk) patientsEarly stage (high risk) patients
Over 70% had one or more Over 70% had one or more symptoms present 1-3 symptoms present 1-3 months before diagnosis:months before diagnosis:
• Abdomino-pelvic pain (38%)Abdomino-pelvic pain (38%)• Fullness / girth (27%)Fullness / girth (27%)• Abnormal bleeding (16%)Abnormal bleeding (16%)
Chan et al, SGO 2009
John K. ChanJohn K. Chan
Gynecologic Cancers
Screening on ovarian cancer mortality: Screening on ovarian cancer mortality: Prostate, Lung, Colorectal and Ovarian (PLCO) TrialProstate, Lung, Colorectal and Ovarian (PLCO) Trial
Total 388 cancersTotal 388 cancers212 screened (5.7 / 10,000 212 screened (5.7 / 10,000 person years)person years)
176 unscreened (4.7 / 10,000 176 unscreened (4.7 / 10,000 person years)person years)
No reduction in ovarian No reduction in ovarian cancer mortality. cancer mortality.
False-positive screening test False-positive screening test result associated with result associated with complicationscomplications
Buys JAMA 2011
78,216postmenop
ausal women
aged 55 to 74 years
(1993-2001)Usual care(n=39,111)
Annual screening
CA-125 - 6 years
TV ultrasound - 4 years
(n=39,105)
John K. ChanJohn K. Chan
Gynecologic Cancers
Ovarian cancerOvarian cancer
• 1 out of 70 U.S. women 1 out of 70 U.S. women • 25,000 cases annually25,000 cases annually• 14,000 deaths annually 14,000 deaths annually • 44thth in cancer related deaths among women in cancer related deaths among women• Mean age at diagnosis 59 yearsMean age at diagnosis 59 years
John K. ChanJohn K. Chan
Gynecologic Cancers
Female Reproductive TractFemale Reproductive Tract New CasesNew Cases DeathsDeaths
Breast Breast 192,200 192,200 40,20040,200
Colorectal 68,100 Colorectal 68,100 29,00029,000
Lung/Bronchus 78,800 Lung/Bronchus 78,800 67,30067,300
Endometrium 38,300 Endometrium 38,300 6,6006,600
OvaryOvary 23,400 23,400 13,90013,900
CervixCervix 13,900 13,900 4,4004,400
Vulva 3,600 800Vulva 3,600 800
American Cancer Society
John K. ChanJohn K. Chan
Gynecologic Cancers
Reproductive factorsReproductive factors
• Increased risk - Increased risk - • NulliparityNulliparity• InfertilityInfertility
• Decreases risk -Decreases risk -• Oral contraceptives Oral contraceptives
protective - 50% decrease protective - 50% decrease with 5 or more years of use.with 5 or more years of use.
• MultiparityMultiparity• LactationLactation
John K. ChanJohn K. Chan
Gynecologic Cancers
Primary Therapy – ovarian cancerPrimary Therapy – ovarian cancer
• Goals of SurgeryGoals of Surgery– DiagnosisDiagnosis
– Staging (early stage disease)Staging (early stage disease)
– Cytoreduction (advanced disease)Cytoreduction (advanced disease)
• Adjuvant ChemotherapyAdjuvant Chemotherapy– Except stage IA or IB and grade I or II or clear cell histologyExcept stage IA or IB and grade I or II or clear cell histology
John K. ChanJohn K. Chan
Gynecologic Cancers
Platinum + Taxane ChemotherapyPlatinum + Taxane Chemotherapy(Carboplatin + Paclitaxel)(Carboplatin + Paclitaxel)
Surgery with maximum Surgery with maximum cytoreduction effortcytoreduction effort
John K. ChanJohn K. Chan
Gynecologic Cancers
• Significant survival advantage for Significant survival advantage for women optimally cytoreducedwomen optimally cytoreduced
• Procedures may include:Procedures may include:– En blocEn bloc resection of uterus, resection of uterus,
ovaries and pelvic tumorovaries and pelvic tumor– OmentectomyOmentectomy– Selective lymphadenectomySelective lymphadenectomy– Bowel resectionBowel resection– Removal of diaphragmatic Removal of diaphragmatic
and peritoneal implants and peritoneal implants – Splenectomy, appendectomySplenectomy, appendectomy
20
22
24
26
28
30
32
34
36
38
40
0 10 20 30 40 50 60 70 80 90 100
% Cytoreduction
Med
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Su
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Mo
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Bristow, J., Clin. Oncol. 20: 1248, 2002
John K. ChanJohn K. Chan
Gynecologic Cancers
US News and World ReportUS News and World Report
Liou, Chan J. Surg Onc 2005Tewari, Chan SGO 2013
Intraperitoneal vs. IV therapyLong- term Survival
• Median PFS25.0 vs 20.0 mo,
p=0.02
• Median OS62.0 vs 51.0 mo,
p=0.048
Tewari, Chan SGO 2013
Gross vs Microscopic Disease
• IP therapy– Advantages in both
microscopic and macroscopic residual disease
– 65% vs 58% microscopic– 44% vs 35% gross
residualGross residual 1.82-fold
increase in risk for death
John K. ChanJohn K. Chan
Gynecologic Cancers
BevacizumabBevacizumab (rhuMAB VEGF) (rhuMAB VEGF)
• Recombinant humanized Recombinant humanized monoclonal IgGmonoclonal IgG11 antibody antibody11
• Recognizes all isoforms of VEGF-ARecognizes all isoforms of VEGF-A22
• Estimated half-life Estimated half-life is approximately 20 days (range, 11-is approximately 20 days (range, 11-50 days)50 days)11
• Randomized trials establish efficacy Randomized trials establish efficacy in colon, breast, lung, and renal in colon, breast, lung, and renal cancercancer
1. Avastin [package insert]. South San Francisco, CA: Genentech, Inc.; 2007; 2. Presta, et al. Cancer Res. 1997;57:4593.
John K. ChanJohn K. Chan
Gynecologic Cancers
Mechanism of action of anti-angiogenic agentsMechanism of action of anti-angiogenic agents
Regression1,2 Inhibition1Normalisation2
Reduces tumor mass
Enhances activity of concomitant therapies
Prevents growth of micrometastases
Efficacy of continued therapy
Continued effects
1. Baluk et al. Curr Opin Genet Dev 20052. Willett et al. Nat Med 2004
Early effects
John K. ChanJohn K. Chan
Gynecologic Cancers
GOG-0218 study schemaGOG-0218 study schema
Previously untreated epithelial ovarian, primary
peritoneal, or fallopian tube cancer
• Stage III optimal (macroscopic)• Stage III suboptimal• Stage IV
n=1800 (planned)
Stratification variables:• GOG performance status• Stage/debulking status
1:1:1
15 months
Paclitaxel 175 mg/m2
Carboplatin AUC 6
Placebo
IArm
Cytotoxic (6 cycles)
Maintenance(16 cycles)
(CP + PLA → PLA)
Carboplatin AUC 6
Paclitaxel 175 mg/m2
PlaceboBevacizumab
15 mg/kg
II(CP + BEV→ PLA)
Bevacizumab 15 mg/kg
Carboplatin AUC 6
Paclitaxel 175 mg/m2III
(CP + BEV BEV)
Burger et al. J Clin Oncol 2010;28(18S): Abstr LBA1
John K. ChanJohn K. Chan
Gynecologic Cancers
GOG-0218: Investigator-GOG-0218: Investigator-Assessed PFSAssessed PFS
Arm I Arm I CP CP
(n=625)(n=625)
Arm IIArm IICP + BEVCP + BEV(n=625)(n=625)
Patients with event, n (%)Patients with event, n (%)423 423
(67.7)(67.7)418 418
(66.9)(66.9)
Median PFS, monthsMedian PFS, months 10.310.3 11.211.2
Stratified analysis HR Stratified analysis HR (95% CI)(95% CI)
0.9080.908(0.759(0.759––1.040)1.040)
One-sided p-value (log rank)One-sided p-value (log rank) 0.080*0.080*
+ BEV (Arm II)+ BEV (Arm II)CP (Arm I)CP (Arm I)
*p-value boundary = 0.0116*p-value boundary = 0.0116
+ BEV + BEV → BEV maintenance (Arm III)→ BEV maintenance (Arm III)
Pro
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rog
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fre
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rop
ort
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su
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pro
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Months since randomizationMonths since randomization
1.01.0
0.90.9
0.80.8
0.70.7
0.60.6
0.50.5
0.40.4
0.30.3
0.20.2
0.10.1
00 00 1212 2424 3636
Arm IIIArm IIICP + BEV CP + BEV BEV BEV
(n=623)(n=623)
360 360 (57.8)(57.8)
14.114.1
0.717 0.717 (0.625(0.625––0.824)0.824)
<0.0001*<0.0001*
2323
John K. ChanJohn K. Chan
Gynecologic Cancers
GOG-0218: Overall Survival GOG-0218: Overall Survival Analysis Analysis
At time of final PFS analysis (January 2010)At time of final PFS analysis (January 2010)
+ BEV (Arm II)+ BEV (Arm II)CP (Arm I)CP (Arm I)
+ BEV + BEV → BEV maintenance (Arm III)→ BEV maintenance (Arm III)
Arm IArm ICPCP
(n=625)(n=625)
Arm IIArm IICP + BEVCP + BEV(n=625)(n=625)
Arm IIIArm IIICP + BEV CP + BEV
BEVBEV(n=623)(n=623)
Patients with events, n (%)Patients with events, n (%) 156 (25.0)156 (25.0) 150 (24.0)150 (24.0) 138 (22.2)138 (22.2)
Median OS, monthsMedian OS, months 39.339.3 38.738.7 39.739.7
Stratified analysisStratified analysisHR (95% CI)HR (95% CI)
1.0361.036(0.827(0.827––1.297)1.297)
0.9150.915(0.727(0.727––1.152)1.152)
One-sided p-valueOne-sided p-value 0.3610.361 0.2520.252
Pro
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Months since randomizationMonths since randomization
1.01.0
0.90.9
0.80.8
0.70.7
0.60.6
0.50.5
0.40.4
0.30.3
0.20.2
0.10.1
00 00 1212 2424 3636 4848
2424
John K. ChanJohn K. Chan
Gynecologic Cancers
1021041061081010
1012
0 2 4 6 8 10 12 14 16 18 20
Conventional chemotherapyConventional chemotherapy
1012
1010
108
106
104
102
1
Dose-dense chemotherapyDose-dense chemotherapy
0 2 4 6 8 10 12 14 16 18 20Larry Norton, The Oncologist 2001;6(suppl 3):30
John K. ChanJohn K. Chan
Gynecologic Cancers
Ovarian Epithelial, Primary Peritoneal, or Ovarian Epithelial, Primary Peritoneal, or Fallopian Tube cancerFallopian Tube cancer
FIGO Stage II-IVFIGO Stage II-IV
Ovarian Epithelial, Primary Peritoneal, or Ovarian Epithelial, Primary Peritoneal, or Fallopian Tube cancerFallopian Tube cancer
FIGO Stage II-IVFIGO Stage II-IV
Conventional TC (c-TC)Conventional TC (c-TC) Paclitaxel 180mg/mPaclitaxel 180mg/m22, day 1, day 1 Carboplatin AUC 6.0, day 1Carboplatin AUC 6.0, day 1 every 21 days for 6-9 cyclesevery 21 days for 6-9 cycles
Conventional TC (c-TC)Conventional TC (c-TC) Paclitaxel 180mg/mPaclitaxel 180mg/m22, day 1, day 1 Carboplatin AUC 6.0, day 1Carboplatin AUC 6.0, day 1 every 21 days for 6-9 cyclesevery 21 days for 6-9 cycles
Dose-dense weekly TC (dd-TC)Dose-dense weekly TC (dd-TC) Paclitaxel 80mg/mPaclitaxel 80mg/m22, days 1,8,15, days 1,8,15 Carboplatin AUC 6.0, day 1Carboplatin AUC 6.0, day 1 every 21 days for 6-9 cyclesevery 21 days for 6-9 cycles
Dose-dense weekly TC (dd-TC)Dose-dense weekly TC (dd-TC) Paclitaxel 80mg/mPaclitaxel 80mg/m22, days 1,8,15, days 1,8,15 Carboplatin AUC 6.0, day 1Carboplatin AUC 6.0, day 1 every 21 days for 6-9 cyclesevery 21 days for 6-9 cycles
RandomizationRandomizationStratification; Stratification;
Residual disease: Residual disease: <<1cm, > 1cm1cm, > 1cmFIGO StageFIGO Stage : : II vs. III vs. IVII vs. III vs. IVHistologyHistology : : clear cell/mucinous vs.serous/others clear cell/mucinous vs.serous/others
N. Katsumata, Lancet 2009
John K. ChanJohn K. Chan
Gynecologic Cancers
Treatment n Event 3-yr survival P value HR 95%CI
c-TC 319 124 65.1%
dd-TC 312 96 72.1% 0.0325 0.749 0.574-0.976
0 6 12 18 24 30 36 42 48 54 60
0.0
0.2
0.4
0.6
0.8
1.0
Months from randomization
Pro
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Pro
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Overall survival
John K. ChanJohn K. Chan
Gynecologic Cancers
ConclusionsConclusions
• Dose-dense paclitaxel with 3 weekly carboplatin should be a Dose-dense paclitaxel with 3 weekly carboplatin should be a new standard chemotherapy for ovarian cancernew standard chemotherapy for ovarian cancer
• Limitations – Limitations –
Pharmacogenetic and tumor difference – asians vs. non-asiansPharmacogenetic and tumor difference – asians vs. non-asians
toxicity and efficacytoxicity and efficacy
less convenientless convenient
more toxicmore toxic
global implicationsglobal implications
John K. ChanJohn K. Chan
Gynecologic Cancers
GOG 262GOG 262
3-weekly IV paclitaxel 175 mg/m2
IV carboplatin AUC 6 q3w
Bevacizumab 15 mg/kg q3w Suboptimal stage III/IV epithelial
ovarian, PP or FT cancer
Bevacizumab 15 mg/kg q3w
Weekly IV paclitaxel 80 mg/m2
IV carboplatin AUC 6 q3w
Open: SEPT 2010Open: SEPT 2010Target Accrual:Target Accrual: 625 pts625 pts Optional* bevacizumab on cycle 2 x 6 then maintenance Optional* bevacizumab on cycle 2 x 6 then maintenance
bevacizumab 15 mg/kg IV day 1 every 21 days until bevacizumab 15 mg/kg IV day 1 every 21 days until progression or adverse effects preclude further treatment.progression or adverse effects preclude further treatment.
Chan J PIChan J PI
John K. ChanJohn K. Chan
Gynecologic Cancers
Recurrent Ovarian Cancer - Recurrent Ovarian Cancer - What is the Optimal Agent, Optimal Dose, & ScheduleWhat is the Optimal Agent, Optimal Dose, & Schedule
John K. ChanJohn K. Chan
Gynecologic Cancers
Ovarian Carcinoma: Natural HistoryOvarian Carcinoma: Natural History
SymptomsSymptomsSymptomsSymptoms
DiagnosisDiagnosis
Chemotherapy #1Chemotherapy #1Chemotherapy #1Chemotherapy #1
Surgical EvaluationSurgical Evaluation
EvaluationEvaluation? SLL? SLL
ProgressionProgression
Chemo #2Chemo #2Chemo #2Chemo #2 Chemo #3+Chemo #3+Chemo #3+Chemo #3+
SupportiveSupportiveCareCare
DeathDeath
ConsolidationConsolidationConsolidationConsolidation
Curative intentCurative intent Palliative intentPalliative intent
SecondarySecondarySurgerySurgery
John K. ChanJohn K. Chan
Gynecologic Cancers
Molecular therapyMolecular therapy– block receptorblock receptor– inhibit tyrosine kinaseinhibit tyrosine kinase– conjugate ligandconjugate ligand– anti-sense ligandanti-sense ligand
Signal transduction
Celldeath
MAbsToxin
conjugates Antisense
Proteinsynthesis
KKKK
Ligand
KK
Signal transduction
TKIs
TKIKK
Ligand Ligand Ligand
Small MoleculesSmall Molecules
John K. ChanJohn K. Chan
Gynecologic Cancers
mRNAExpressionArray CGH Mutations
SensitivityPredictor
Predicting Sensitivity: An Integrated Approach
John K. ChanJohn K. Chan
Gynecologic Cancers
• 13,321 women with ovarian cancer in California.
• Only a third of patients received the best possible care by NCCN
• More experienced surgeons (>10 ovarian cancer and hospitals that treated >20 year) associated with better outcomes
John K. ChanJohn K. Chan
Gynecologic Cancers
The Role of the physicians in Early DetectionThe Role of the physicians in Early Detection
• Consider referral or consultation - Gynecologic OncologistConsider referral or consultation - Gynecologic Oncologist
– Postmenopausal and one of the following:Postmenopausal and one of the following:
• elevated CA125, ascites, nodular or fixed mass, metastasis, elevated CA125, ascites, nodular or fixed mass, metastasis,
or family history of breast or ovarian canceror family history of breast or ovarian cancer
– Premenopausal and one of the following: Premenopausal and one of the following:
• elevated CA125 (>200), ascites, metastasis, or family elevated CA125 (>200), ascites, metastasis, or family
history of breast or ovarian cancerhistory of breast or ovarian cancer
ACOG Committee Opinion #280, December 2002
John K. ChanJohn K. Chan
Gynecologic Cancers
Kaplan-Meier 5 yr disease-specific survival - gynecologic oncologist careKaplan-Meier 5 yr disease-specific survival - gynecologic oncologist care
Gynecologic oncologist Gynecologic oncologist 39% 39% (p<0.001)(p<0.001)No gynecologic oncologist No gynecologic oncologist 30% 30%
Gyn Onc (n=509)
No Gyn Onc (n=982)
Northern CaliforniaNorthern CaliforniaCalifornia Cancer California Cancer RegistryRegistry
1994 and 1996 1994 and 1996 1,491 women1,491 womenstage IC-IV ovarian stage IC-IV ovarian cancercancer
Chan et al Obgyn 2007
John K. ChanJohn K. Chan
Gynecologic Cancers
Early-stage:Early-stage: Late-stage:Late-stage:Gynecologic oncologist Gynecologic oncologist 66% 66% Gynecologic oncologist Gynecologic oncologist 31% 31%No gynecologic oncologist No gynecologic oncologist 61% 61% No gynecologic oncologist No gynecologic oncologist 23% 23%(p=0.157)(p=0.157) (p<0.001)(p<0.001)
Gyn Onc (n=398)
No Gyn Onc (n=692)
Kaplan-Meier five-year disease-specific survival based on Kaplan-Meier five-year disease-specific survival based on gynecologic oncologist caregynecologic oncologist care
Gyn Onc (n=100)
No Gyn Onc (n=211)
Chan et al Obgyn 2007
John K. ChanJohn K. Chan
Gynecologic Cancers
Chronic stress promotes tumor growth and angiogenesis
Thaker, Sood Nat Med 2006Thaker, Sood Nat Med 2006
Animals showed markedly Animals showed markedly increased vascularization andincreased vascularization andtumor growth via cAMP–PKA tumor growth via cAMP–PKA signaling pathwaysignaling pathway
Mouse model of ovarian cancerMouse model of ovarian cancerTumors in stressedTumors in stressed
John K. ChanJohn K. Chan
Gynecologic Cancers
Cervical Cancer Cervical Cancer
John K. ChanJohn K. Chan
Gynecologic Cancers
The Global Burden of Cancer to Women WorldwideThe Global Burden of Cancer to Women Worldwide
Parkin DM et al CA Cancer J Clin 2005;55;74-108
John K. Chan, M.D.John K. Chan, M.D.
Screening Guidelines - Review
Initiate
Screening interval
DiscontAge 21-29 Age >30
ACS / ASCCP / ASCP (2012)
21 Cytology every three years
Co-testing HPV and cytology every five years (preferred)Cytology every three years (acceptable)
65
US Preventive Services Task Force (2012)
21 Cytology every three years
Cytology every three yearsAlternative: co-testing HPV and cytology every five years¥
65
ACOG (2012)
21 Cytology every three years
Co-testing HPV and cytology every five years (preferred)Cytology every three years
65
John K. ChanJohn K. Chan
Gynecologic Cancers
Biology of HPV Infection: High-Grade LesionsBiology of HPV Infection: High-Grade Lesions11–3–3
*CIN = cervical intraepithelial neoplasia; ICC = invasive cervical cancer1. Goodman A, Wilbur DC. N Engl J Med. 2003;349:1555–1564. Adapted with permission from the Massachusetts Medical Society. 2. Doorbar J. J Clin Virol. 2005;32(suppl):S7–S15. 3. Bonnez W. In: Richman DD, Whitley RJ, Hayden FJ, eds. Washington, DC: American Society for Microbiology Press; 2002:557–596.
Normal Normal CervixCervix
HPV Infection HPV Infection (CIN* 2) (CIN* 3)(CIN* 2) (CIN* 3)
Cervical Cancer Cervical Cancer (Invasive)(Invasive)
Infectious Viral Particles
Episome
Perinuclear Clearing (Koilocytosis)
Basal cell layer
John K. ChanJohn K. Chan
Gynecologic Cancers
John K. ChanJohn K. Chan
Gynecologic Cancers
Yeast Cell (or Yeast Cell (or Baculovirus Expression System)
L1 gene L1 gene on HPV on HPV
DNADNA
L1 gene inserted L1 gene inserted into genome of into genome of
yeast cellyeast cell
Yeast cell DNAYeast cell DNA
mRNAmRNAtRNAtRNA
rRNArRNA
TranscriptionTranscription
TranslationTranslation
Capsid proteinsCapsid proteins
Empty viral capsids
Elicits Elicits immune immune
response in response in hosthost
HPV L1 VLP Vaccine SynthesisHPV L1 VLP Vaccine Synthesis
John K. ChanJohn K. Chan
Gynecologic Cancers
Chan, Berek JCO 2007
John K. ChanJohn K. Chan
Gynecologic Cancers
Prophylactic HPV VaccinesProphylactic HPV Vaccines
• Quadra-valent (Merck)Quadra-valent (Merck)– Recombinant L1 proteins using yeastRecombinant L1 proteins using yeast– 100% effective in preventing 100% effective in preventing
persistent HPV infectionpersistent HPV infection– Phase III Study completedPhase III Study completed
• HPV L1 Types 6, 11, 16 & 18 vs. HPV L1 Types 6, 11, 16 & 18 vs. adjuvantadjuvant
• Endpoint CIN2+Endpoint CIN2+
• Bi-valent (GSK)Bi-valent (GSK)– Recombinant L1 proteins using Recombinant L1 proteins using
baculovirusbaculovirus
– 100% effective in preventing persistent 100% effective in preventing persistent HPV infectionHPV infection
– Phase III study ongoingPhase III study ongoing• HPV L1 Types 16 & 18 vs. Hepatitis AHPV L1 Types 16 & 18 vs. Hepatitis A• Endpoint CIN 2+Endpoint CIN 2+
Villa LL et al Lancet Oncol. 2005 May;6(5):271-8.
Harper DM et alLancet. 2004 Nov 13-19;364(9447):1757-65.
John K. ChanJohn K. Chan
Gynecologic Cancers
Advisory Committee on Immunization Practices —(Pediatric, gynecologic, and family practice)
females aged 11 to 12 (as young as age 9)Catch-up vaccination 13 to 26 years (Bivalent or quadrivalent)
males aged 11 or 12 years (as young as 9)Catch-up 13 to 21 years (Quadrivalent)
John K. ChanJohn K. Chan
Gynecologic Cancers
ConclusionsConclusions
• The incidence of cervical cancer is decreasingThe incidence of cervical cancer is decreasing• Vaccines will eliminate this disease in a generationVaccines will eliminate this disease in a generation• Multimodality therapy in almost every scenario of invasive Multimodality therapy in almost every scenario of invasive
diseasedisease• Clinical and translational trials ongoing investigating new Clinical and translational trials ongoing investigating new
agentsagents
John K. ChanJohn K. Chan
Gynecologic Cancers
Uterine CancerUterine Cancer
John K. ChanJohn K. Chan
Gynecologic Cancers
Robotic Surgical SystemRobotic Surgical System
• Unparalleled Precision Dexterity and Unparalleled Precision Dexterity and ControlControl– High resolution 3D visualizationHigh resolution 3D visualization– Fully articulating Fully articulating EndoWristEndoWrist®® instruments instruments– Intuitive movement, motion scaling, Intuitive movement, motion scaling,
tremor reductiontremor reduction
John K. ChanJohn K. Chan
Gynecologic Cancers
Robotic surgery – public perceptionRobotic surgery – public perception
John K. ChanJohn K. Chan
Gynecologic Cancers
Robotic surgery vs. laparoscopic Robotic surgery vs. laparoscopic surgery surgery
Safe and feasible. ?better than Safe and feasible. ?better than laparoscopylaparoscopyAdvantages - Decreases physician Advantages - Decreases physician tremor, fatiguetremor, fatigueDisadvantages - Increase OR time, Disadvantages - Increase OR time, cost, bulky, no tactile feedbackcost, bulky, no tactile feedbackTransition from open to laparoscopic Transition from open to laparoscopic surgery, Market pressuressurgery, Market pressures
Evidence based practice vs. state of Evidence based practice vs. state of art (novel technologies)art (novel technologies)
Venkat, Chan et al, Gyn Onc 2011
John K. ChanJohn K. Chan
Gynecologic Cancers
ReviewReview
• Ovarian cancerOvarian cancer– Surgery – optimal surgery – high volume surgeonsSurgery – optimal surgery – high volume surgeons– Adjuvant chemotherapy – intraperitoneal & weekly therapyAdjuvant chemotherapy – intraperitoneal & weekly therapy
• Cervix cancerCervix cancer– Prevention – New screening & HPV vaccine Prevention – New screening & HPV vaccine
• Endometrial cancer Endometrial cancer – Robotic LaparoscopyRobotic Laparoscopy