Randomized Controlled Trial Using Novel Markers to Predict Malignancy in Elevated Risk Women
Early detection, a key to improved outcomes for women with ovarian cancer, is a major focus of our research program. During the previous funding period we worked to recommend a set of markers and an algorithm that can be used in a clinical trial for ovarian cancer screening to prevent ovarian cancer from escaping early detection. Achievement of this goal required the development of a novel statistical model to identify promising markers, as well as the evaluation of several currently existing and novel markers using serum specimens from three separate studies for ovarian cancer screening.
To date, project investigators have successfully developed two algorithms that have been described in several publications (see list below). The first, the Parametric Empirical Bayes (PEB) Method, is used to screen for cancer using markers measured over time and tailors the screening decision rule to the individual woman. The second combines theoretical and practical work to characterize (1) the optimal method to combine two markers, and (2) a practical way to estimate this combination. Both algorithms have been employed to evaluate the performance of several ovarian cancer biomarker candidates.
The most promising of these markers is HE4, identified and developed by our group during our first SPORE funding cycle. We are now poised to evaluate HE4 in a prospective, randomized controlled trial (RCT). We will use an epithelial ovarian cancer risk model incorporating serum markers and other risk factors along with conventional pedigree and mutation data to select women for screening. For the prospective evaluation of HE4 we have assembled a team of experienced clinical investigators at four clinical sites including Beth Karlan, MD at Cedars-Sinai Medical Center (CSMC) in Los Angeles, Paula Hillard, MD at Stanford in Palo Alto, Pam Paley, MD at Swedish Cancer Institute (SCI) in Seattle, Melanie Palomares, MD at City of Hope (COH) in Duarte, California and Mary Daly, MD, PhD at Fox Chase Cancer Center (FCCC) in Philadelphia, Pennsylvania.
We will conduct a Phase I trial to compare two multimodal screening strategies. The first strategy (Arm 1) uses both CA125 and HE4 in a first-line screen to select women for imaging. The second strategy (Arm 2) uses CA125 alone as a first-line screen to select women for imaging and HE4 testing. Because CA125 and HE4 exhibit greater variability among women than within a woman over time, the parametric empirical Bayes (PEB) longitudinal algorithm will be used to interpret rise in either marker as a signal of disease in first-line screens (3). Surgical consult will be indicated if any 2 of the 3 modalities is positive. Three additional experimental markers will also be measured but will not be acted upon in the absence of compelling evidence in their favor. If one or more equally promising new markers emerges prior to or during the period of the study, those markers will be measured and, if evidence is sufficiently compelling, added as a first- or second-line screen.
Women aged 25-80 will be eligible for semi-annual screening if they have a documented deleterious mutation in BRCA1 or BRCA2. Women aged 35-80 will be eligible for semi-annual screening if they have another mutation or a pedigree suggestive of inherited susceptibility. Women aged 45-80 will be eligible for annual screening if they have serum marker levels or other risk factors conferring elevated risk. Although this is a RCT, as a Phase I trial it is intended to assess safety and feasibility. We will test the null hypotheses that the two screening strategies do not differ with respect to compliance with the screening protocol, surgical procedures performed per cancer detected, and cancer worry among women experiencing false positives.
For more information about participation in this study, please click here.
The study protocol is summarized in this PDF document.
For additional details about this trial, please visit ClinicalTrials.gov.
Project 1 Publications
1. Karlan BY, Thorpe J, Watabayashi K, Drescher CW, Palomares M, Daly MB, Paley P, Hillard P, Andersen MR, Anderson G, Drapkin R, Urban N. Use of CA125 and HE4 serum markers to predict ovarian cancer in elevated-risk women. [In Press: Cancer Epidemiology, Biomarkers and Prevention]. PubMed Link ↗
2. Urban N, Thorpe J, Karlan BY, McIntosh MW, Palomares MR, Daly MB, Paley P, Drescher CW. Interpretation of single and serial measures of HE4 and CA125 in asymptomatic women at high risk for ovarian cancer. Cancer Epidemiol Biomarkers Prev. 2012 Nov;21(11):2087-94. PMCID: PMC3493821. PubMed Link ↗
3. Cramer DW, Bast RC, Berg CD, Diamandis EP, Godwin AK, Hartge P, Lokshin AE, Lu KH, McIntosh MW, Mor G, Patriotis C, Pinsky PF, Thornquist MD, Scholler N, Skates SJ, Sluss PM, Srivastava S, Ward DC, Zhang Z, Zhu CS, Urban N. Ovarian Cancer Biomarker Performance in Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial Specimens. Cancer Prev Res (Phila). 2011 Mar;4(3):365-74. PMCID: PMC3085251. PubMed Link ↗
4. Urban N. Designing early detection programs for ovarian cancer. Annals of Oncology 2011 Dec;22 (Supplement 8): viii16–viii18. doi:10.1093/annonc/mdr472. PMCID: PMC3280618. PubMed Link ↗
5. Urban N, Thorpe JD, Bergan LA, Forrest RM, Kampani AV, Scholler N, O'Briant KC, Anderson GL, Cramer DW, Berg CD, McIntosh MW, Hartge P, Drescher CW. Potential role of HE4 in multimodal screening for epithelial ovarian cancer. J Natl Cancer Inst. 2011 Nov 2;103(21):1630-4. PMCID: PMC3206037. PubMed Link ↗
6. Zhu CS, Pinsky PF, Cramer DW, Ransohoff DF, Hartge P, Pfeiffer RM, Urban N, Mor G, Bast RC, Moore LE, Lokshin AE, McIntosh MW, Skates SJ, Vitonis A, Zhang Z, Ward DC, Symanowski JT, Lomakin A, Fung ET, Sluss PM, Scholler N, Lu KH, Marrangoni AM, Patriotis C, Srivastava S, Buys SS, Berg CD. For the PLCO Project Team. A Framework for Evaluating Biomarkers for Early Detection: Validation of Biomarker Panels for Ovarian Cancer. Cancer Prev Res (Phila). 2011 Mar;4(3):375-83. PMICD: PMC3057372. PubMed Link ↗
7. Anderson GL, McIntosh MW, Wu L, Barnett M, Goodman G, Thorpe JD, Bergan L, Thornquist MD, Scholler N, Kim N, O'Briant K, Drescher C, Urban N. Assessing Lead Time of Selected Ovarian Cancer Biomarkers: A Nested Case–Control Study. J Natl Cancer Inst. 2010 Jan 6;102(1):26–38. PMCID: PMC2802285. PubMed Link ↗
8. Shah CA, Lowe KA, Paley P, Wallace E, Anderson GL, McIntosh MW, Andersen MR, Scholler N, Bergan LA, Thorpe JD, Urban N, Drescher CW. Influence of Ovarian Cancer Risk Status on the Diagnostic Performance of the Serum Biomarkers Mesothelin, HE4, and CA125. Cancer Epidemiol Biomarkers Prev. 2009 May;18(5):1365-72. PMCID: PMC2714056. PubMed Link ↗