Recent advances in treating newly diagnosed, advanced ovarian cancer have focused on better surgery, namely, by gynecologic oncologists attempting to achieve compete resection. When complete resection is not feasible, neoadjuvant chemotherapy has become common, with surgery then being performed after 3 cycles. Chemotherapy has also changed. In a single Japanese study, dose-dense weekly paclitaxel (80 mg weekly without a break) combined with every-3-week carboplatin prolonged progression-free survival (PFS) and overall survival (OS). Another advancement in first-line treatment is adding bevacizumab. This appears to be most effective in those with large-volume residual disease after debulking and in stage IV patients where survival may be improved by about 8 months.

How have treatments changed for recurrent ovarian cancer over the last 5 years?

Bradley J. Monk, MD, FACOG, FACS, discusses case studies in ovarian and cervical cancer. He explains that s

he had a recurrence 18 months after initial therapy. This is termed &lsquo;platinum-sensitive&rsquo; disease and is generally treated with a platinum doublet. The CALYPSO trial showed that carboplatin plus pegylated liposomal doxorubicin (PLD) outperforms carboplatin plus paclitaxel in PFS, toxicity, and convenience. A third platinum combination would include gemcitabine, which gained US Food and Drug Administration (FDA) approval in 2006. Adding bevacizumab to this regimen in the OCEANS trial improved PFS (hazard ratio [HR] 0.48) but had no impact on OS, given the long postprogression survival. Bevacizumab can also be safely combined with carboplatin and paclitaxel or PLD. I think all patients with epithelial ovarian cancer should receive bevacizumab at some point. The risk of bowel perforation increases with each successive round of treatment, making earlier antivascular endothelial growth factor (VEGF) therapy safest. In November 2014, bevacizumab gained FDA approval in combination with single-agent chemotherapy when the platinum-free interval is less than 6 months (platinum-resistant disease).

Bradley J Monk, MD, FACOG, FACS Antiangiogenesis Therapy

Bradley J. Monk, MD, FACOG, FACS, discusses case studies in ovarian and cervical cancer. Dr. Monk explains that t

his patient is not a good candidate for secondary debulking, given the diffuse nature of her recurrent disease, and likely has carcinomatosis. Ascites is commonly associated with carcinomatosis and with bloating and impaired quality of life. Anti-VEGF therapy is particularly effective in ascites and a predictor of improved quality of life when used in the platinum-resistant patient.

Bradley J Monk, MD, FACOG, FACS Ascites Impact on Quality of Life

Bradley J. Monk, MD, FACOG, FACS, explains that Sarah

is an ideal candidate for supportive care, such as nutritional support, exercise, psychosocial counseling, and neuropathy management.

Bradley J Monk, MD, FACOG, FACS Options to Controlling Recurrent Metastatic Disease

Bradley J. Monk, MD, FACOG, FACS, explains that n

o single regimen can clearly prolong OS. Long survival is likely a result of multiple active regimens used in sequence. PARP inhibitors are being investigated even in nongerm- line BRCA carriers to help prolong PFS after response to second- and third-line platinum-based regimens.

Bradley J Monk, MD, FACOG, FACS Options That May Prolong Survival 

Krishnansu S. Tewari, MD, FACOG, FACS says

here are 3 areas in which treatment for ovarian cancer has changed over the last 5 years. Recognizing the importance of cytoreductive surgery, the benchmark of &lsquo;optimal cytoreduction&rsquo; has now become achieving zero gross residual disease after surgery rather than no greater than 1-cm volume residual disease. Secondly, there are several new chemotherapeutic agents that have been studied in prospective clinical trials, including pemetrexed, trabectedin, and the hypomethylating agent decitabine. Unfortunately, none of these new chemotherapeutic agents are FDA approved. Thirdly, biologic agents have been studied extensively, particularly antiangiogenesis agents and PARP inhibitors. Despite 8 phase III, randomized trials involving 5 different antiangiogenesis agents in primary advanced and recurrent ovarian cancer, only bevacizumab has been recently approved for platinum-resistant recurrent disease. The PARP inhibitor olaparib was approved by the FDA on December 19, 2014, for fourth-line therapy of women with BRCA 1/2 mutations. Other targeted/biologic agents being studied include vascular disrupting agents, aurora kinase inhibitors, and Notch pathway inhibitors (gamma secretase inhibitors).

Krishnansu S Tewari, MD, FACOG, FACS Change in Recurrent Ovarian Cancer Over 5 Years

Krishnansu S. Tewari, MD, FACOG, FACS would reccomend

Krishnansu S Tewari, MD, FACOG, FACS Antiangiogenesis Therapy

Krishnansu S. Tewari, MD, FACOG, FACS discusses how a

scites can cause significant bloating and feelings of early satiety, pressure on the bladder, and even difficulty with bowel movements and breathing.

Krishnansu S. Tewari, MD, FACOG, FACS: Ascites Impact on Quality of Life

Krishnansu S. Tewari, MD, FACOG, FACS says that s

ince this patient is platinum-sensitive, options include cisplatin, carboplatin, or oxaliplatin combined with either gemcitabine, pegylated liposomal doxorubicin, or topotecan. Although not FDA-approved for platinum- sensitive patients, bevacizumab at 15 mg/kg has been shown to improve PFS in platinum-sensitive patients in the OCEANS study when combined with carboplatin plus gemcitabine. Since she has had a long disease-free interval of 3 years and appears on imaging to only have surface liver metastasis and a solitary splenic nodule, a consideration for laparoscopy could be entertained with plans to perform a secondary cytoreductive surgery with or without heated intraperitoneal chemotherapy if limited disease is indeed encountered.

Krishnansu S. Tewari, MD, FACOG, FACS: Options to Controlling Recurrent Metastatic Disease

n relation to options available for controlling Sarah's recurrent metastatic disease, all of these options may improve PFS. A significant impact on OS, however, is unlikely and has not been shown previously in clinical trials for recurrent disease.

Krishnansu S. Tewari, MD, FACOG, FACS says that i

Gynecologic Cancers: Case 1