A 59-Year Old Woman With Stage IIIC Ovarian Cancer - Episode 6

Extended Maintenance Therapy in Ovarian Cancer

Jubilee Brown, MD:When we counsel our patients regarding the duration of maintenance bevacizumab, typically I counsel my patients based on the GOG-0218 and ICON7 trials. And so really what we’re looking at is a year of post-treatment maintenance therapy with bevacizumab. There is a study by Amit Oza, MD, that evaluates, should we keep this going for longer? And I think that we don’t necessarily have definitive answers from that at this point. What we know is that in this large study that Dr Oza did, the patients can be continued for a long period with some increase in adverse effects but rarely having to discontinue their therapy. I think time will tell if we should continue therapy for longer than that additional year on maintenance. But I think that, at this point, most of us use 1 year of maintenance therapy after.

One additional consideration for this patient actually would be the incorporation of olaparib into her treatment regimen for maintenance therapy. The PAOLA-1 trial evaluated specifically that question in patients with advanced epithelial ovarian cancer. Regardless ofBRCAmutation, these patients were given olaparib and bevacizumab versus placebo and bevacizumab. Now, we don’t know what a placebo-only arm would have looked like, but we do see an improvement in outcomes with these patients who had olaparib and bevacizumab together compared to bevacizumab alone. So interestingly, this is an option to discuss with patients, to consider 2 years of olaparib in addition to bevacizumab for evenBRCA-negative patients.

This is a very exciting time for development of therapy for patients with ovarian cancers. We have so many options at this point and so many that are continuing to develop. For a long time, we were sort of stuck with standard chemotherapy, and now in addition to PARP [poly ADP ribose polymerase] inhibitors, we have small molecule inhibitors. We have immunotherapy. We have so many different options for treatment. The question is really how to potentially combine those treatments and which patients to use which treatments for at which time. So I think it is an exciting time. We’ll figure out how to incorporate molecular testing. We’ll figure out how to incorporate the combinations of these therapies as well as novel therapies in the future.

It will be really exciting to see what comes of the IMagyn050 trial. Basically, this is incorporating atezolizumab in combination with paclitaxel, carboplatin, and bevacizumab. Hopefully, we’ll be able to have interesting results from this in the very near future.

I think it’s an exciting time for patients. Obviously, no one wants to be diagnosed with ovarian cancer, but the options that we have for our patients now are simply so much better than they used to be. We can really tailor therapy, and we can limit morbidity, and we can effect cures in patients where we simply didn’t know how to do that in the past. So it’s a good time to be a GYN [gynecologic] oncologist and a better time to have ovarian cancer.

Transcript edited for clarity.


Case: A 59-Year Old Female With Stage IIIC Ovarian Cancer

Initial Presentation

  • A 59-year old female presented with new onset early satiety, abdominal bloating and discomfort
  • PMH: unremarkable, postmenopausal
  • SH: schoolteacher; no tobacco, alcohol or drug use
  • PE: abdominal distention, left lower quadrant tender on palpation, shifting dullness noted on percussion

Clinical work-up

  • Pelvic exam with transvaginal ultrasound showed a left ovarian mass
  • Chest/abdomen/pelvis CT with contrast revealed a left adnexal 4.8-cm mass, extension to liver capsule without parenchymal involvement; retroperitoneal lymph node involvement and ascites noted; no pleural effusion
  • Lymph node, adnexal mass biopsy, and paracentesis (2000 cc) cytology confirmed high-grade epithelial ovarian cancer
  • Diagnosis: high-grade epithelial ovarian cancer; stage IIIC — T3cN1M0
  • Germline/molecular testing showed HRD-,BRCA1/2wild—type
  • CA-125, 385 U/mL
  • ECOG PS 1

Treatment

  • Patient underwent TAH/BSO, lymph node dissection, with optimal debulking; R0
  • IP/IV paclitaxel/carboplatin + bevacizumab every 3 weeks for 6 cycles
    • Followed by bevacizumab for 6 more cycles
    • Complete response; post treatment CA—125, 48 U/mL

Follow-up

  • 3-months CA-125, 30 U/mL
  • Chest/abdomen/pelvis CT showed no gross pelvic masses or nodes
  • Pelvic exam, unremarkable
  • ECOG PS 0