A 59-Year-Old Woman with Ovarian Cancer - Episode 3

Ovarian Cancer: Systemic Front-Line Treatments

Dr Chirag A. Shah explains the front-line treatment options for ovarian cancer and the factors considered in choosing maintenance therapies.

Chirag A. Shah, MD: Of the FDA-approved treatments for first-line maintenance, we have PARP inhibitor therapy. PARP inhibitors can be given in monotherapy for all women who have responded to platinum-based treatment, such as this patient who reached a complete response to treatment; she would be an ideal candidate. Given the fact that she has a homologous recombination deficiency [HRD], she’s likely to have a robust response to a PARP inhibitor. The next class of drugs that’s approved in first line, whichpredated the PARP inhibitor approval, which I’m sure many of you who are watching this are familiar with, is bevacizumab. Antiangiogenic therapy has been proven to be effective in women with ovarian cancer in all lines of therapy. Recent research, including from the MITO series of trials, suggests that bevacizumab can be given in the first line, can be given later, and is still effective; that’s a very commonly used drug.

Where people use bevacizumab is really all over the map. In my experience, who decides to give bevacizumab to which patients is quite variable. I tend to use the approach of tailoring my highest-risk patients, those patients who are stage IV, who have suboptimally debulked disease, to think that those patients would benefit from bevacizumab. That is because that decision is often made very early in the time of treatment, sometimes before you even have any testing results back; it’s just based upon the clinical appearance of the patient. In addition, there’s approval for combination PARP and bevacizumab in patients who have HRD or a BRCA mutation based upon the PAOLA series of trials. From the large-scale PRIMA trial, we have approval for niraparib, as was used in this case. Then from the series of GOG trials, and also the ICON trials in Europe, bevacizumab has been approved in the first line, and then the PAOLA trials, as I previously mentioned.

One of the questions that invariably comes up when you start a patient on maintenance therapy is what that duration of maintenance therapy should be. The initial bevacizumab trials that we alluded to primarily treated the patient for 1 additional clinical year. I’m a gynecologic oncologist by trade, I’ve been long comfortable with maintenance therapy, but this is newer to the gynecologic oncology realm in ovarian cancer. But bevacizumab was initially shown to be effective in the trials that it was administered in on a 12-month basis. The niraparib approval that was based off the large, randomized PRIMA trial treated patients for 3 years. Given the fact that that’s an oral therapy, I think that was more palatable. We enrolled and recruited patients and had patients on the PRIMA trial and found that that duration of therapy didn’t feel to be an obstacle to treatment. It still becomes difficult when you’ve had a patient on maintenance for an extended period to decide if it’s OK to take them off. I tend to follow what was done in the clinical trials. If I’m using Avastin [bevacizumab], I will typically stop that at a year afterward because these drugs can have toxicity. If I’m treating with a PARP, I’ll generally follow with 3 years, as long as the patient hasn’t progressed during that period.

Transcript edited for clarity.