HE4 – Human Epididymal Protein 4A novel oncological biomarker improving ovarian cancer care

Worldwide, ovarian cancer is the second leading cancer in women and the fourth common cause of dying from cancer. It is a gynecological disease with one of the highest mortality rates. The highest incidence is found in industrialized nations like North America, Europe, Australia and New Zealand. Worldwide more than 200,000 women are diagnosed with this disease and 140,000 die from it.1 Although therapeutic options like new pharmaceuticals and surgery have improved over the last years, the prognosis is still disappointing. The more the disease has progressed, the lower the survival rate is and unfortunately most of the ovarian cancer cases are detected in later stages where the chances for a cure are rather low.

In the early stages of ovarian cancer symptoms are unspecific and cause little, if any, discomfort. Later, women may suffer from so-called pelvic or adnexal masses which can result in abdominal pain. It is estimated that 5 to 10 percent of women will present with a pelvic mass to their physician during their lifetime and undergo a surgical procedure for a suspected ovarian malignancy. In approx. 13 to 21 percent of these women, ovarian malignancies will be found.2

Therefore, new methods and biomarkers which can help in diag-nosing this disease at an earlier stage are highly desirable.

The new biomarker HE4 (human epididymal protein 4) together with the already established marker CA125 can play a very important role here.

Human epididymal protein 4 (HE4) was first detected in the epithelia of the distal epididymis.3 In epithelial ovarian cancer (EOC) tissue and in serum of patients with EOC, very high concentrations of HE4 can be found.4 Therefore, the risk assessment of epithelial ovarian cancer (EOC) is expected to be supported by measuring HE4.

Furthermore, HE4 was also shown to be an independent prognostic marker for ovarian cancer.5

Ovarian cancer

< 14.6< 8.5< 6.4< 4.9< 3.7

Fig. 1: Estimated age-standardized incidence rate per 100,000 (Ovary, all ages)1

Only stage I of epithelial ovarian cancer is limited to the ovaries

APM HEINTZ, F ODICINO et al

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Clinical background of ovarian cancer

Fig. 2: Carcinoma of the ovary. Staging ovarian cancer: primary tumor and metastases (FIGO and TNM) 6

Early diagnosis of epithelial ovarian cancer is still a big challenge

75 % of patients with EOC show symptoms only at later stages (stages III – IV). Most of these symptoms are rather vague like increases of the abdomen, pelvic abdominal pain, or urge to urinate. Often the disease has progressed at this point where there is a decreased survival rate.7

Survival rate in ovarian cancer patients is clearly dependent on the type and quality of surgery to remove the tumor as completely as possible. The highest survival rate can be achieved when treatment is done in centers specialized in gynecologic oncology.8

Improvement in 5-year disease free survival for EOC I patients was observed without tumor rupture during surgery compared with those with tumor rupture.9

1. Clinical background5

-yea

r su

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70605040302010

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Fig. 3: 5-year survival rate in ovarian cancer is dependent from stage. Graph adapted from Salani, R., et al. (2009)7

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Surgeon Gynecologist Gynecol. Oncologist

Fig. 4: Kaplan-Meier survival curve of women with progressive epithelial ovariancancer after surgery depending on the type of treating physician. Graph adapted from Paulsen, T., et al. (2006)8

2. Importance of oncological biomarkers to support the early detection of ovarian cancer

The combination of HE4 and CA125 is more sensitive in detecting EOC than either marker alone

In a study by Moore et al., sensitivities of various oncological biomarkers were compared at different specificities in samples from 233 patients with 67 invasive ovarian cancers and 166 benign ovarian neoplasias.10

•Asasingletumormarker,HE4hadthehighestsensitivityfordetecting ovarian cancer, especially stage I disease

•ThecombinationofCA125andHE4added33.1%tothesensitivityof CA125 alone and 3.5% to the sensitivity of HE4 alone S

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%] 70

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CA125 HE4 CA125 + HE4

90% Spec

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98% Spec

23.9

64.271.6

Fig. 5: Sensitivities of CA125 and HE4 at different specificities for differentiatingbenign disease from ovarian cancer (all stages) 10

In a study by Montagnana et al., HE4 and CA125 values of patients with EOC in different stages were compared to a control group.11

•CA125showedagooddiscriminationbetweencontrolsandcancer patients only in later stages

•HE4showedagooddiscriminationbetweencontrolsandcancerpatients also in early stages

•Detectionofearlystagesofovariancancer–whereCA125alone shows limited diagnostic performance – benefits from the supplementary use of HE4

10

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Fig. 6: Comparison of CA 125 and HE4 in differentiating healthy women fromwomen with early cancer stages. Graphs adapted from Montagnana, M., et al. (2009)11

HE4 helps to differentiate ovarian endometriotic cysts from ovarian cancer

In a study by Huhtinen, K., et al. (2009), serum CA125 and HE4 concentrations of a control group were compared with patients with several stages of endometriosis, endometrial cancer (EmCa) and epithelial ovarian cancer (EOC).12

•CA125canalsobeincreasedinendometriosis•HE4showsabetterdifferentiationbetweencancerand

endometriosis•HE4allowsabetterdifferentiationbetweenbenignand

malignant diseases than CA125•Bothbiomarkerstogetherprovidevaluableinformation

to discriminate ovarian malignancies from benign ovarian endometriotic cysts

Ctrln=66

Stage 1n=16

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Stage 3n=24

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M]

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Fig. 7: Comparison of CA 125 and HE4 in differentiating various stages of endometriosis from ovarian cancer. Graph adapted from Huhtinen, K., et al. (2009)12

HE4 and CA125 can be combined in a mathe matical algorithm to better assess the risk of EOC in women with a pelvic mass

Risk assessment with the ROMA score (risk of ovarian malignancy algorithm):

The score is used to calculate the risk of having EOC in women arriving at the physician with a pelvic mass. It includes the biomarker levels of HE4 and CA125 and also considers the menopausal status of the woman.

The dual marker combination can be used to classify women into high and low risk groups allowing for the effective triage of women to appropriate surgical centers for their care.13

PI = -12.0 + 2.38*LN[HE4] + 0.0626*LN[CA125] PI = -8.09 + 1.04*LN[HE4] + 0.732*LN[CA125]

Fig. 8: Calculation of the ROMA-values for pre- and post-menopausal women and individual cut-points for the Elecsys assays to separate between low and high risk patients

Pelvic mass: Risk of ovarian malignancy algorithm (ROMA)

Pre-menopausal

<11.1% ≥11.4% low risk high risk

Post-menopausal

<29.9% ≥29.9% low risk high risk

(exp(PI) = ePI)

ROMA-value [%] = exp(PI) / [1 + exp(PI)] * 100

ROMA with Elecsys® HE4 and CA125 classifies 94% of all women correctly

The effectiveness of the Elecsys HE4 assay in combination with the Elecsys CA125 assay for risk estimation of EOC of patients presenting with pelvic mass was determined in an international multicenter clinical trial using repository samples. A total of 384 patient samples were included and the predictive probability for ovarian cancer as well as the ability for separation into a low and a high risk group based on ROMA values were determined.14

The cut-points above of 11.1% and 29.9% for pre- and post-menopausal women respectively were used in order to provide a specificity level of 75 % for the Elecsys HE4 and Elecsys CA 125 assay combi-nation.

•94%ofallwomenwereclassifiedcorrectly•ThesensitivityforstratifyingpatientswithstageI-IVepithelial

ovarian cancer into the high risk group was 84.3 % at a specificity of 75 %.

•Thepositiveandnegativepredictivevalueswere64.9%and90%respectively.

•AUC(95%-CI): Pre-menopausal women = 0.858 (0.779-0.937)

Post-menopausalwomen=0.923(0.885-0.962)

0.0 0.50.40.30.20.1 0.6 0.7 0.8

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Pre-menopausal woman Post-menopausal woman

Fig. 9: ROC graph for ROMA using Elecsys HE4 and CA125 for pre- andpost-menopausal women for differentiating benign diseases from ovarian cancer (all stages)

HE4 supports CA125 to better monitor ovarian cancer

In addition to the use of HE4 and CA125 for the risk stratification of women with a pelvic mass, HE4 can be used to monitor the diseasestatusinovariancancerpatients.BothbiomarkersCA125 and HE4 are of complementary nature. While in most of the cancer patients both markers are expressed in significant amounts, there are patients who are positive for only one of the biomarkers HE4 and CA125. Thus the combined use of CA125 and HE4 could facilitate the detection of recurrent disease by reducing the number of biomarker negative patients and delivering more confidence when both markers show increasing values.

The use of HE4 during primary chemotherapy of EOC was evaluated by Hynninen, J., et al. (2011) and it could be shown that the profile of HE4 during primary chemotherapy was in line with radiologic and clinical responses. In the neoadjuvant chemotherapy group, HE4 correlated better with the radiologic response than CA 125.16

The effectiveness of the Elecsys HE4 assay as an aid in monitoring of disease status in ovarian cancer patients was determined by assessing changes in HE4 levels in serial serum samples from 100 patients compared to changes in disease status. A study involving a total of 375 pairs of observations was undertaken with ≥ 3 blood withdrawals per patient.

A change in HE4 concentration of > 20 percent suggested recurrence or disease progression, while a decrease of this magnitude suggested therapeutic response.14

3. The clinical value of HE4 in disease monitoring and follow-up

The combined use of HE4 and CA125 has a significant predictive value

The combination of HE4 and CA125 appears to have a significant value in predicting optimal surgical outcome and development of resistant disease in platinum-based chemotherapy treated EOC patients.Elevatedplasmalevels6monthsafter1stlinechemo-therapy significantly correlate with overall and progression-free survival in platinum-sensitive patients.15

•Reductionofbiomarker-negative ovarian carcinomas

•Improvesriskstratificationofpelvicmasspatients and triage to specialists

•HighersensitivityofHE4improves early diagnosis of EOC

•Detectsrecurrenceearlier

Benefits of HE4 and CA125

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References1 Globocan2008cancerdatabase,inforetrievalAugust2012:http://globocan.iarc.fr

2 NationalInstitutesofHealthConsensusDevelopmentConferenceStatement.(1994).OvarianCancer:screening,treatment, and follow-up. Gynecol Oncology, 55, 3(2): 4-14.

3 Kirchhoff, C. (1998). Molecular characterization of epididymal proteins. Rev Reprod., 3(2):86-95.4 Drapkin,R.,vonHorsten,H.H.,Lin,Y.,Mok,S.C.,Crum,C.P.,Welch,W.R.,Hecht,J.L.(2005).Humanepididymis

protein 4 (HE4) is a secreted glycoprotein that is overexpressed by serous and endometrioid ovarian carcinomas. Cancer Res, 65(6):2162-9.

5 Steffensen,K.D.,Waldstrøm,M.,Brandslund,I.,Jakobsen,A.(2011).Prognosticimpactofprechemotherapyserumlevels of HER2, CA125, and HE4 in ovarian cancer patients. Int J Gynecol Cancer, 21(6): 1040-7.

6 Heintz,A.P.,Odicino,F.,Maisonneuve,P.,Quinn,M.A.,etal.(2006).Carcinomaoftheovary.FIGO26thAnnualReport on the Results of Treatment in Gynecological Cancer. Int J Gynaecol Obstet, 95 Suppl 1:S161-92.

7 Salani,R.,Backes,F.J.,Copeland,L.J.(2009).Overviewofepithelialovariancancerandupdatesinmanagementstrategies. Expert Rev. Obstet. Gynecol., 4, 383-399.

8 Paulsen,T.,Kjaerheim,K.,Kaern,J.,Tretli,S.,Tropé,C.(2006).Improvedshort-termsurvivalforadvancedovarian,tubal, and peritoneal cancer patients operated at teaching hospitals. Int J Gynecol Cancer;16 Suppl 1: 11-7.

9 Paulsen, T., Kærn, J., Tropé C. (2011). Improved 5-year disease-free survival for FIGO stage I epithelial ovarian cancer patients without tumor rupture during surgery. Gynecol Oncol.; 122(1): 83-8.

10 Moore,R.G.,Brown,A.K.,Miller,M.C.,Skates,S.,etal.(2008).Theuseofmultiplenoveltumorbiomarkersforthedetection of ovarian carcinoma in patients with a pelvic mass. Gynecol Oncol.;108(2): 402-8.

11 Montagnana,M.,Lippi,G.,Ruzzenente,O.,Bresciani,V.,etal.(2009).Theutilityofserumhumanepididymisprotein4(HE4) in patients with a pelvic mass. J Clin Lab Anal.;23(5): 331-5.

12 Huhtinen, K., Suvitie, P., Hiissa, J., Junnila, J., et al. (2009). Serum HE4 concentration differentiates malignant ovarian tumours from ovarian endometriotic cysts. Br J Cancer;100(8): 1315-9.

13 Moore,R.G.,McMeekin,D.S.,Brown,A.K.,DiSilvestro,P.,etal.(2009).AnovelmultiplemarkerbioassayutilizingHE4 and CA125 for the prediction of ovarian cancer in patients with a pelvic mass. Gynecol Oncol.;112(1): 40-6.

14 DatafromtheRochemulticenterstudyonElecsys® HE4. (2011). implemented from the Elecsys HE4 package insert.15 Braicu,I.,Cherekov,R.,Richter,R.,Vergote,I.B.,etal.(2012).UseofHE4andCA125topredictsurgicaloutcomeand

for prognostic value for progression-free survival (PFS) and overall survival (OS) in primary epithelial ovarian cancer (EOC) patients (pts). J Clin Oncol 30 (suppl; abstr 5034).

16 HynninenJ.,Auranen,A.,Dean,K.,Lavonius,M.,etal.(2011)SerumHE4ProfileDuringPrimaryChemotherapyofEpithelial Ovarian Cancer. Int J Gynecol Cancer;21(9): 1573-8.