Expert Perspectives on Treating Recurrent Ovarian Cancer - Episode 8

Future Treatment of Ovarian Cancer

March 26, 2021
Shannon Westin, MD

The future of ovarian cancer treatment is discussed through a summary of current treatment options, future directions, and a review the unmet needs facing patients and physicians today.

Shannon Westin, MD: We have been so excited over the last few years to have this wealth of new maintenance strategies available to patients with ovarian cancer, but we still have a little way to go. As we talked about in this patient case, our best outcomes for patients with chemotherapy followed by maintenance are for patients who either have BRCA1 or BRCA2 mutations, whether that’s germline or somatic, or for patients whose tumors test positive with or have evidence of homologous or combination deficiency. We can still see benefit for patients with a homologous or combination proficient disease, but it is not as profound. This is a huge unmet need, so we are really maximizing maintenance strategies for that particular population. To that end, there are a number of really exciting trials—the majority have all enrolled, or maybe only a few are still enrolling—and we are anticipating results over the next few years looking at combinations.

These trials are being done with all comers, so we’ll see results in patients with BRCA mutations. We will see results for patients with a homologous or combination deficient disease, but we are all waiting with bated breath to see if we get a benefit for patients with combination strategies who have homologous or combination proficient disease. Some of those combination strategies are incorporating PARP inhibition with immunotherapy or immuno-oncology agents. Some are combining PARP with immunotherapy and antiangiogenics like bevacizumab. Two drugs are good; maybe 3 drugs are better. We are going to determine if these combinations of 2 or 3 drugs are enough to overcome that resistance and really help.

All these trials are ongoing, and they will be looking at that progression-free survival benefit to see if we can extend the time. They will all have overall survival as secondary outcomes as well, and that is an area we are very excited about, an area where we are eagerly anticipating results over the next few years. Of course, if we are giving more patients PARP inhibitors up front, the question remains: What are we going to do if they do have a recurrence and their tumor is resistant to PARP? There are a number of really exciting trials on the horizon that will be looking at ways to overcome resistance to PARP inhibitors, so that we really get benefit again from these important drugs.

Transcript edited for clarity.

Case: A 68-Year-Old Woman With Recurrent Ovarian Cancer

Initial Presentation

  • A 68-year-old female presented with abdominal bloating, discomfort and decreased appetite
  • PMH: unremarkable, postmenopausal; no known family history of cancer
  • PE: abdominal distention, right lower quadrant tenderness on palpation

Clinical work-up

  • Pelvic exam with transvaginal ultrasound showed a right ovarian mass
  • Chest/abdomen/pelvis CT with contrast revealed a right adnexal 4-cm mass, inguinal lymph node involvement and ascites, no pleural effusion
  • Lymph node, adnexal mass biopsy, and paracentesis (1500 cc) cytology confirmed high-grade epithelial ovarian cancer
  • Germline molecular testing: HRD+, BRCA1/2-
  • CA-125, 385 U/mL
  • Diagnosis: Stage 4, high-grade epithelial ovarian cancer
  • ECOG PS 0

Treatment

  • Patient underwent TAH/BSO, lymph node dissection, with optimal debulking; R0
  • IP/IV paclitaxel/carboplatin; PR
  • Followed by niraparib maintenance