Case 1: Observation Versus Maintenance Therapy in Ovarian Cancer

Thomas C. Krivak, MD: She was treated with IV/IP [intravenous/intraperitoneal] cisplatin/paclitaxel, and she has a complete response. CA-125 [cancer antigen 125] goes to 14.2U/mL, and she’s without evidence of disease, which is what we want for all our patients.

At this point again, she’s BRCA wild type, HRD [homologous recombination deficiency]-positive based off the Myriad myChoice test. What’s our decision tree? She can be observed, niraparib maintenance, bevacizumab plus olaparib. If you started them on bevacizumab, and if you follow the guidelines, OVARIO was just presented. It’s not labeled yet, but combination niraparib with bevacizumab; AVANOVA as well with OVARIO is out there, and that may come later. These are the treatment decisions that we can make at this point. What are the recommended niraparib doses based off of body weight as well as platelet count?

You can see over there on the right, 49-year-young patient, had advanced stage ovarian cancer, germline tested. I wouldn’t observe anybody. HRD is predictive and prognostic. I know people will debate that for a long time, and I’m sure that we’ll still be debating it in a couple of years, but I don’t observe anybody at this point. Whether they’re HR [homologous recombination]-proficient or HRD-negative, I would treat. If I started them on bevacizumab, I would go with bevacizumab and olaparib at this point. I love the absolute PFS [progression-free survival] change with bevacizumab and olaparib versus bevacizumab alone. It was a very interesting presentation this last SGO [Society of Gynecologic Oncology Annual Meeting on Women’s Cancer] where they looked at the PAOLA and the SOLO patients. I need to wait for that paper to understand the statistics, but I was fascinated by that presentation and saw that you are potentially getting an added effect even in the patients with a BRCA mutation. Those are all 3 observations. My weight would be bevacizumab plus olaparib, probably number 1; number 2, you can switch somebody off of bevacizumab to niraparib alone; and observation the lowest choice at this point.

It’s nice that we have all these new approvals because, if you’re going through treating somebody, and they have a massive PE [pulmonary embolism] and you can’t give them Avastin [bevacizumab] or feel comfortable with Avastin, you could use single-agent olaparib. Some people would do that, but if you go by NCCN [National Comprehensive Cancer Network guidelines], you could switch over to niraparib. If somebody is having bad thrombocytopenia, and you don’t feel they can tolerate niraparib, then you have a combination of olaparib and bevacizumab. We’ve been doing this in our group [at the Allegheny Health Network] since ESMO [the European Society for Medical Oncology Congress] and have attached the papers and have had quite good success getting both the niraparib approved in this instance, as well as bevacizumab and olaparib approved. It was great presentation at ESMO, and the data are compelling. Observation is an excellent scientific question, but as a clinician, I want to treat the patients, so I would do some type of maintenance therapy. I’m curious to hear what you guys think.

Transcript edited for clarity.