Considerations Regarding Newly Diagnosed Ovarian Cancer

Robert L. Coleman, MD:The impact of surgery in ovarian cancer has been well established for many years. We’ve know that there’s probably a pretty strong relationship between the amount of postoperative residual disease and survivorship. The key there is that the biology that defines the natural history of ovarian cancer actually is related to the ability to get all the tumor out at the time of surgery. So, that’s quite important.

What I will say about staging from the standpoint of this particular patient is that staging is less of a major issue because we know she already has metastatic disease. Where it becomes very important is in patients who have suspected limited-stage disease. For instance, if we had a patient such as this who did not have ascites in her omental cake but who had a large pelvic mass, it would be very important for us to establish that she actually has or doesn’t have metastatic disease. That has not only prognostic implications, but it also has an implication about whether or not therapy should be administered at all. What I mean by that is that there are patient populations, for instance, with early-stage grade 1 or 2 disease that don’t need chemotherapy. It’s important from a staging standpoint to identify those patients who are in need of adjuvant therapy, which for the most part is almost all patients. But in a patient like this who presents with metastatic disease, ascites, and omental caking, staging is really less of a primary issue with regard to management than debulking, and that’s what she had done.

Many patients ask the question about prognosis, and I want to get to something right off the bat for the audience. Prognosis is a population statistic. It’s fine if we’re talking about a group of women with stage 3C ovarian cancer. What does that mean? We talk about this prognosis and we talk about it from the standpoint of median survivorship or what the likelihood is that somebody will be alive in 5 years. What’s the likelihood that somebody will not ever need chemotherapy again after they finish their frontline treatment? Those are prognostic representations of prognosis.

Prognosis on an individual basis is almost undefinable. We know that there are factors that lead to better outcomes and longer outcomes. But in an individual patient, if you have those particular characteristics that are defined as good prognosis, we have no way of ensuring that an individual patient—what is called the n of 1—is actually going to follow that track. I try to get out of the prognosis discussion when I talk on an individual basis, but from the standpoint of understanding the disease, there are many, many prognostic variables. One of the major prognosis factors is stage. Certainly, patients with earlier stage do better than patients with later stage.

The treatment goals for any patient who has ovarian cancer is cure. That’s it, bottom line. That’s what we want to achieve. We try to do the best surgery, the best chemotherapy, and the best surveillance so that patients are cured. Now, we know from historical data and our ongoing real-time experience that we don’t cure all patients with ovarian cancer. Those who present like this patient with metastatic disease are even more difficult to cure. But that’s the end goal. All of the work that we do, all of our clinical trials, all the work that we do in the recurrent setting—all that’s focused on 1 specific endpoint, and that’s cure.

Transcript edited for clarity.

December 2016

• A 38-year old female presented with bloating and pain
• PMH: unremarkable
• FH: no malignancy
• Abdominal/pelvic CT scan: pelvic mass (9-cm) arising from the right ovary, omental cake (15-cm), and extensive peritoneal carcinomatosis
• CA-125: 1027 U/mL
• The patient was diagnosed with stage IIIC epithelial ovarian cancer
• She underwent hysterectomy, bilateral salpingo-oophorectomy, and omentectomy
  • Scattered residual peritoneal nodules (<1 cm) remained following surgery
• Following surgery, treated with 6 cycles of IP/IV carboplatin/paclitaxel
  • After 6 cycles of therapy, CA-125 level declined to 2.5 U/mL
  • Symptoms were ameliorated

March 2017

• Patient reported bloating and abdominal pain
• Lab results showed elevated CA 125 (985 U/mL)
• CT scan confirmed recurrence with ascites and visible disease (2-cm peritoneal mass)
• She was treated with bevacizumab and topotecan for 4 cycles
  • Patient had good response therapy
  • After 4 cycles, she was switched to bevacizumab maintenance

October 2017

• Patient returned with complaint of abdominal pain
• CT scan revealed ascites and several 1- to 2-cm peritoneal masses in the pelvis and upper abdomen