ONCAlert | Upfront Therapy for mRCC

Case 2: Treating BRCA-Mutated Ovarian Cancer

Targeted Oncology
Published Online:12:32 PM, Wed May 29, 2019


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Robert L. Coleman, MD: OK, so what did we decide on treatment? Bevacizumab? No bevacizumab?

Shannon N. Westin, MD: I think we decided that every 3 weeks, and no bevacizumab.

Robert L. Coleman, MD: OK, so every 3 weeks, paclitaxel with carboplatin, and no bevacizumab.

Shannon N. Westin, MD: No bevacizumab.

Robert L. Coleman, MD: All right. If you go to the NCCN [National Comprehensive Cancer Network] Guidelines, no matter what answer it was, I think every answer, even the 1 you came up with, would be right on target. OK, so they’re all candidates. Now what?

Shannon N. Westin, MD: We’re likely going to treat about 6 cycles, and then we typically reassess and make sure we’ve gotten what we wanted—meaning there’s no evidence of new disease.

Robert L. Coleman, MD: So you’re going to go 6 cycles and then reimage?

Shannon N. Westin, MD: Yes.

Robert L. Coleman, MD: Or just test for CA 125 [cancer antigen 125]? Do you reimage after 6 cycles of chemotherapy?

David O’Malley, MD: I do. Many of my partners do not. I think it’s a nice baseline.

Susana M. Campos, MD, MPH: I completely agree, yeah.

David O’Malley, MD: You have a group of patients who are going to have lymphocysts, which in the future may be misinterpreted disease.

Robert L. Coleman, MD: OK, and then what?

Shannon N. Westin, MD: So prior to all this treatment, I’ve already been counseling her. This is, again, a known BRCA patient. We’ve been talking about the fact that this is not going to be the end of therapy. So at the completion of chemotherapy, give her a few weeks off. And then, typically within about 3 to 4 weeks, start her on olaparib.

Robert L. Coleman, MD: OK. What’s your standard approach to that? Regarding that first cycle, what do you do? Do you do it differently?

Shannon N. Westin, MD: Well, I think a lot of this is counseling, right? So first, of course, the goal is for the patient to live longer without disease. But you don’t want to be adding additional toxicity. This is a population for which typically, before this, it was surveillance. They were on nothing. They were feeling good, and they were off treatment. This is their window. This is kind of their honeymoon time. So you want to make sure that you make it as much of a honeymoon as possible. And so it’s really important to counsel these patients and make sure they know that even though this isn’t chemotherapy, there are adverse effects. But they’re manageable.

We generally see our patients once a month when they’re on olaparib maintenance, but we do make sure they have ample access to the clinic team so that if they start to have nausea or any symptoms that make us concerned, we can intervene before that 1-month time point. You don’t want someone to be struggling through that first month with fatigue and nausea and things like that and then be done with treatment.

Robert L. Coleman, MD: And we know that treatment modifications are frequent with these drugs.

Shannon N. Westin, MD: Absolutely.

David O’Malley, MD: So that’s part of our counseling. Around half of patients will require a dose reduction. They all go home with antiemetics, and we follow up with them within the first week with a telephone call, but then see them monthly. Part of that education is right from the beginning. But managing often includes dose reduction and antiemetics or other medications for fatigue.

Shannon N. Westin, MD: We often send people home with a prophylactic antiemetic. We don’t necessarily tell them they have to take it, but we counsel them just like you did with chemotherapy. “If you find that you’re starting to have nausea, then go ahead and take that 30 minutes to an hour before you take your drug, and see if that doesn’t get you where you need to be.”

Susana M. Campos, MD, MPH: So I cheat a little bit. I actually do the reverse, OK? Let’s pick a PARP [poly (ADP ribose) polymerase] inhibitor like olaparib. I start at an intermediate dose, like 200 [mg], you know, twice a day. And then I give it for a week. I give it for a week and a half, and I acclimate the dose to 300 [mg], which actually saved me a lot of dose reductions in the course of time. I know that’s not how you’re supposed to do it, but that’s how we do it.

Robert L. Coleman, MD: No. Actually, in practicality, we were doing that as well, absolutely.

David O’Malley, MD: And the dosing and the availability to escalate or deescalate is sometimes easier at those doses.

Transcript edited for clarity.


EXPERT PERSPECTIVE VIRTUAL TUMOR BOARD

Robert L. Coleman, MD: OK, so what did we decide on treatment? Bevacizumab? No bevacizumab?

Shannon N. Westin, MD: I think we decided that every 3 weeks, and no bevacizumab.

Robert L. Coleman, MD: OK, so every 3 weeks, paclitaxel with carboplatin, and no bevacizumab.

Shannon N. Westin, MD: No bevacizumab.

Robert L. Coleman, MD: All right. If you go to the NCCN [National Comprehensive Cancer Network] Guidelines, no matter what answer it was, I think every answer, even the 1 you came up with, would be right on target. OK, so they’re all candidates. Now what?

Shannon N. Westin, MD: We’re likely going to treat about 6 cycles, and then we typically reassess and make sure we’ve gotten what we wanted—meaning there’s no evidence of new disease.

Robert L. Coleman, MD: So you’re going to go 6 cycles and then reimage?

Shannon N. Westin, MD: Yes.

Robert L. Coleman, MD: Or just test for CA 125 [cancer antigen 125]? Do you reimage after 6 cycles of chemotherapy?

David O’Malley, MD: I do. Many of my partners do not. I think it’s a nice baseline.

Susana M. Campos, MD, MPH: I completely agree, yeah.

David O’Malley, MD: You have a group of patients who are going to have lymphocysts, which in the future may be misinterpreted disease.

Robert L. Coleman, MD: OK, and then what?

Shannon N. Westin, MD: So prior to all this treatment, I’ve already been counseling her. This is, again, a known BRCA patient. We’ve been talking about the fact that this is not going to be the end of therapy. So at the completion of chemotherapy, give her a few weeks off. And then, typically within about 3 to 4 weeks, start her on olaparib.

Robert L. Coleman, MD: OK. What’s your standard approach to that? Regarding that first cycle, what do you do? Do you do it differently?

Shannon N. Westin, MD: Well, I think a lot of this is counseling, right? So first, of course, the goal is for the patient to live longer without disease. But you don’t want to be adding additional toxicity. This is a population for which typically, before this, it was surveillance. They were on nothing. They were feeling good, and they were off treatment. This is their window. This is kind of their honeymoon time. So you want to make sure that you make it as much of a honeymoon as possible. And so it’s really important to counsel these patients and make sure they know that even though this isn’t chemotherapy, there are adverse effects. But they’re manageable.

We generally see our patients once a month when they’re on olaparib maintenance, but we do make sure they have ample access to the clinic team so that if they start to have nausea or any symptoms that make us concerned, we can intervene before that 1-month time point. You don’t want someone to be struggling through that first month with fatigue and nausea and things like that and then be done with treatment.

Robert L. Coleman, MD: And we know that treatment modifications are frequent with these drugs.

Shannon N. Westin, MD: Absolutely.

David O’Malley, MD: So that’s part of our counseling. Around half of patients will require a dose reduction. They all go home with antiemetics, and we follow up with them within the first week with a telephone call, but then see them monthly. Part of that education is right from the beginning. But managing often includes dose reduction and antiemetics or other medications for fatigue.

Shannon N. Westin, MD: We often send people home with a prophylactic antiemetic. We don’t necessarily tell them they have to take it, but we counsel them just like you did with chemotherapy. “If you find that you’re starting to have nausea, then go ahead and take that 30 minutes to an hour before you take your drug, and see if that doesn’t get you where you need to be.”

Susana M. Campos, MD, MPH: So I cheat a little bit. I actually do the reverse, OK? Let’s pick a PARP [poly (ADP ribose) polymerase] inhibitor like olaparib. I start at an intermediate dose, like 200 [mg], you know, twice a day. And then I give it for a week. I give it for a week and a half, and I acclimate the dose to 300 [mg], which actually saved me a lot of dose reductions in the course of time. I know that’s not how you’re supposed to do it, but that’s how we do it.

Robert L. Coleman, MD: No. Actually, in practicality, we were doing that as well, absolutely.

David O’Malley, MD: And the dosing and the availability to escalate or deescalate is sometimes easier at those doses.

Transcript edited for clarity.
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