High-Risk Advanced Ovarian Cancer: Chemotherapy Options

Thomas C. Krivak, MD:Using chemotherapy to treat these patients, a lot of folks are going to have different ideas. Some people like using [every-3]-week dosing, so carboplatin [and] paclitaxel every 3 weeks for 6 cycles. Some folks will want to go ahead and use weekly dosing of paclitaxel and [every-3]-week dosing of carboplatin. I think both have pluses and minuses. If you have patients who are driving a good distance for their chemotherapy, it may best to get on [an every-3]-week dosing. Some practitioners believe that a [weekly] dosing of Taxol may increase a little of the response rate as well as decrease some of the [adverse] effects.

To me, I generally prefer the [every-3]-week dosing. And what I’ll do is if the patient gets primary debulked, they’ll go ahead and get their debulking on a surgery, get their first dose of chemotherapy. And then what I prefer to do, especially in this patient—who in my mind is stage IV, [with a] high risk for recurrence—she would have gotten carboplatin [and] paclitaxel on her first treatment, and then starting with course 2 she would have gotten carboplatin [and] paclitaxel with bevacizumab.

To me I think that that’s a really safe way to do it, especially if she required a rectosigmoid resection, or required extensive debulking that [will] allow her to heal. And then after 6 courses of chemotherapy, we assess each time with CA 125. She gets into remission or has a complete or partial response, then [goes] on to additional bevacizumab therapy at that time.

So for this patient I think that we have a couple [of] studies that have been done. You know we’ve had the weekly dosing of Taxol, but regardless of carboplatin and paclitaxel, GOG-0182 was a study that looked at, had patients at times [who] received 8 cycles of chemotherapy and had used novel combinations of doublets and triplet therapy. What we saw that is [that] it was equal outcomes, toxicities were different, but you can potentially substitute some of those drugs for up-front therapy. I’d say most of us would want to do a platinum-taxane-based therapy and then add Avastin in if they believe that’s the right thing to do.

And you know you brought up about talking about maintenance therapy, you brought up how we’re going to incorporate maintenance therapy into this patient. I think Avastin is a very good choice. It’s been FDA approved. Avastin has been used in recurrent ovarian cancer, primary ovarian cancer. If you look at the NCCN [National Comprehensive Cancer Network] Guidelines at this point, Avastin is approved for maintenance therapy, pazopanib is approved for maintenance therapy, [and] Lynparza, or olaparib, is approved for maintenance therapy in patients who have a germline or somatic mutation inBRCA1.

So I think maintenance therapy is important. And in this patient, [who has] high-risk disease, to me I think she’d be an ideal candidate to go on maintenance therapy with Avastin. And I think the question that I would have posed to myself is, I’ll start treating her and base the treatment I just described, [every-3]-week dosing of Taxol and carbo platinum, adding Avastin in, and then putting her on maintenance Avastin. [Because] she’s high risk, sometimes we think, should we keep them on Avastin until they recur or progress because of the high risk of relapse? Or do we just do 15 treatments of bevacizumab after completion of primary chemotherapy?

Transcript edited for clarity.

Case: A 70-Year-Old Woman Presenting With Advanced Ovarian Cancer

H & P:

• A 70-year-old woman presents for evaluation of left-ovary mass discovered during a recent pelvic exam. She reports abdominal tenderness, urinary symptoms, and a “bloated” or “full” feeling, despite normal diet and bowel movements
• Postmenopausal, no children
• PE: reveals a woman of low normal weight (BMI = 19 kg/m²) with hypertension; abdomen is distended and shows dullness to percussion
  • BP = 135/80 mm Hg on metoprolol
  • Fasting glucose = 95 mg/dL
  • LDL = 90 mg/dL

Imaging

• CT with contrast of pelvis, abdomen, and chest reveals multiple peritoneal lesions and spread to outside of liver
• Malignant ascites present

Biopsy and labs:

• Pathology: high-grade epithelioid adenosarcoma, ovarian primary
• BRCA1/2status: unknown
• CA-125: 656 U/mL

Treatment

• She underwent hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and tumor debulking; residual disease after cytoreduction: 1.25 cm
• Diagnosis: stage IV ovarian cancer, grade 3
• Started on carboplatin and paclitaxel plus bevacizumab; achieved a partial response
• She was continued on maintenance bevacizumab

Follow up:

• Follow up imaging at 6 months showed disease progression in the liver
• She was started on paclitaxel plus bevacizumab