Bevacizumab: An angiogenesis inhibitor for the treatment of solid malignancies

Background: Bevacizumab is a recombinant humanized monoclonal antibody that was approved by the US Food and Drug Administration (FDA) in February 2004 for use as part of combination therapy with fluorouracil-based regimens for metastatic colorectal cancer (mCRC). Objectives: This article reviews the mechanism of action, clinical pharmacology, and pharmacodynamic and pharmacokinetic properties of bevacizumab. It summarizes data on the clinical efficacy and tolerability of bevacizumab from Phase II/III trials in mCRC, breast cancer, non-small-cell lung cancer, and renal cell carcinoma and preliminary data from investigational studies in pancreatic cancer and soft-tissue sarcomas. The dosing and administration of bevacizumab also are discussed. Methods: A comprehensive search of the English-language literature indexed on MEDLINE (1966-April 2006) was performed using the terms Avastin, bevacizumab, vascular endothelial growth factor, angiogenesis, and bevacizumab plus colorectal cancer, breast cancer, non-small-cell lung cancer, pancreatic cancer, and renal cell carcinoma. Published abstracts from American Society of Clinical Oncology annual meetings from 2002 to 2006, FDA submission documents, and the product information for bevacizumab also were reviewed. Pertinent review articles, preclinical studies, and editorials and all published Phase II/III clinical trials were selected for review. The reference lists of identified articles were examined for additional publications. Results: Bevacizumab exhibits linear pharmacokinetics in the dose range between 0.3 and 10 mg/kg q2-3wk and steady state, which is reached in similar to 100 days. The estimated t(1/2) of bevacizumab is similar to 20 days. After correction for body weight, clearance and V-d are reported to be a respective 26% and 22%) higher ill men than In women. Statistical analyses have not been performed, however, and the clinical impact of these gender differences has not been assessed. No dose adjustment is currently recommended based oil age, sex, or renal function. Bevacizumab has been reported to result in changes in exposure to concomitant chemotherapy, although formal drug-interaction studies have not been performed. Surrogate markets of disease progression or treatment response to bevacizumab have been studied, but no significant correlations with any outcome measure have been found. When combined with standard chemotherapy regimens, bevacizumal) has been associated with significant improvements compared with chemotherapy alone in the efficacy end points of overall survival, progression-free Survival, and response rates in patients with mCRC (all, P < 0.05). Based on these findings, bevacizumab is considered a first-line option for this disease. Combination bevacizumab regimens have been associated with clinical activity in breast cancer, non-small-cell lung cancer, renal cell carcinoma, pancreatic cancer, and soft-tissue sarcoma. The observed toxicities of bevacizumab include hypertension, proteinuria, mild to moderate hemorrhage, wound healing complications, and thromboembolic events. A bevacizumab dose of 5 mg/kg q2wk has been established as effective and well tolerated in the setting of mCRC. A variety of dosing schemes have been investigated in other solid neoplasms, but no consensus has been reached on the optimal bevacizumab regimen. Conclusions: Bevacizumab is effective and generally well tolerated as first-line therapy for mCRC. The results from clinical studies of bevacizumab as a single agent or as part of combination regimens for breast cancer, non-small-cell lung cancer, renal cell carcinoma, and other solid malignancies have been promising. The most effective regimens for various malignancies and predictive markets of treatment response have not been fully determined. Combining bevacizumab with chemotherapy or other novel targeted agents appears to be a rational approach that may enhance efficacy while limiting the traditional nonselective toxicities. (Clin Ther. 2006;28:1779-1802) Copyright (c) 2006 Excerpta Medica, Inc.