Experience Managing Newly Diagnosed Advanced Ovarian Cancer

Bradley J. Monk, MD, FACOG, FACS:I’m happy to report that the era of targeted in gynecologic oncology has arrived. It is part of the frontline treatment of newly diagnosed advanced ovarian cancer with 2 options. In the molecular signature-positive patient—in germlineBRCA1orBRCA2mutations or somatic mutations—those patients can begin maintenance olaparib for 2 years with a 36-month improvement in progression-free survival. And in the molecular signature-negative patients, those patients can have bevacizumab added to the chemotherapy regimen in cycle 2, and it can be continued in maintenance for 15 months with a very dramatic benefit in those with large-volume residual disease, which also includes stage IV patients.

And the beauty of it is that we understand the toxicities. We can manage them. We can manage the olaparib-related toxicities, which include fatigue, bone marrow suppression, and GI [gastrointestinal] toxicities with supportive-care dose reductions and dose delays. We can manage the adverse events associated with anti-angiogenic therapy, which is generally hypertension, and it can be managed without altering the dosing regimen. So the era of targeted therapy is here. I challenge you to understand it. I challenge you to offer it to your patients so that your patients can live longer and live better.

My personal experience with newly diagnosed advanced ovarian cancer is that almost all patients respond and recover. But the opposite is also true. Almost all patients recur and ultimately die. So the best place to improve those outcomes is in the frontline, and the best opportunity is through a maintenance strategy. So we have to get it right in the beginning. Once a patient recurs, she’s destined to serial recurrences, shorter and shorter times to progression, and ultimately, succumbing to her advanced cancer. So let’s get it right in the frontline. Let’s give her the best option to survive or, hopefully, even be cured. With these new targeted therapies and with good surgery, cure rates are approaching as high as 40%.

Patients frequently ask what they can do to improve their outcome. There’s no question that patients who have a more global healthy lifestyle—exercise, diet, low stress, sleep, alcohol in moderation, balanced diet—do better. So we try to coach our patients in this survivorship mode to do their part to try to live the healthiest lifestyle possible.

Transcript edited for clarity.

Case: A 54-Year-Old Woman Diagnosed With Advanced Ovarian Cancer

H & P

• A 54-year-old woman presents after referral from her gynecologist for widespread tenderness, abdominal discomfort, and urinary symptoms. Pelvic exam performed by the gynecologist revealed a suspicious mass on her right ovary.
• Postmenopausal with two children
• PE: reveals an obese woman (BMI = 31 kg/m²) with mild hypertension and pre-diabetes; abdomen shows dullness to percussion
  • BP = 130/85 mm Hg
  • Fasting glucose = 115 mg/dL
  • Waist: hip ratio = 0.90

Imaging

• CT with contrast of the pelvis, abdomen, and chest reveals widespread peritoneal lesions and abdominal lymph node involvement
• Malignant ascites present

Biopsy and labs:

• Pathology, high-grade serous adenocarcinoma, ovarian primary
• BRCA1/2 status: negative
• CA-125: 785 U/mL

Treatment

• She underwent hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and tumor debulking; residual disease after cytoreduction = 1.1 cm
• Diagnosis, stage IIIC ovarian cancer, grade 3
• Started on every-3-week carboplatin and paclitaxel IV plus bevacizumab every 3 weeks