Leslie Randall, MD, considers the possibility of relapse in ovarian cancer and reviews treatment options available at recurrence.
Leslie M. Randall, MD: Let’s pivot and say that this patient does go on the niraparib [Zejula] therapy and continues that for 2 years of the 3 years that is prescribed. They start to have a rise in the CA 125 [cancer antigen 125] and recurrent right lower quadrant pain and you get a CT scan and diagnose metastatic recurrent disease that is in several areas in the peritoneal cavity, which is a common area for recurrence for ovarian cancer. What do we do for that patient next? We said that she’s gotten 2 years out on her therapy and so what we do as GYN [gynecologic]- oncologists is calculate their platinum-free interval. For this patient, it’s greater than 6 months, so she would be considered a platinum-sensitive patient. If she had recurred less than 6 months out from her platinum treatment, she would be considered platinum-resistant and that’s a different treatment pathway.
For patients who classify as platinum-sensitive, we typically re-treat them with a chemotherapy platinum-containing doublet. That would be carboplatin with, either, paclitaxel [Taxol], pegylated liposomal doxorubicin, or gemcitabine [Gemzar]. In this setting, we would also like to follow that with maintenance. This is where the prior maintenance really plays a role in the decision we would make. So patients again, just as in the frontline setting are eligible for either bevacizumab [Avastin] or PARP maintenance. Bevacizumab maintenance can be given in multiple lines of therapy and would definitely be an option here, especially for a patient who received PARP in the frontline. The PARP therapy option is 1 that we’re not sure of yet. So here, you would have a PARP-treated patient who has a platinum-sensitive recurrence and the question is can they receive PARP in the second line of therapy? What is the benefit? We actually have a clinical trial called the OReO trial that was presented this past year at ESMO [European Society for Medical Oncology annual meeting] that compared physicians’ choice treatment to olaparib [Lynparza] re-treatment in patients who had elaborate in the prior maintenance setting. That trial was interesting. It didn’t show a benefit of receiving olaparib and again, in the second line of therapy, but the increment of benefit was fairly small. Many of us interpreting the OReO data think that we still aren’t completely clear on whether we should be giving PARP after PARP yet. Now, some argue that for patients who had a long platinum-free interval and a long disease-free interval on the PARP inhibitor and did not progress on the PARP inhibitor that you can consider re-treating them with a PARP inhibitor. Those patients probably do benefit from second treatment with PARP, but those patients who progress on PARP inhibitor likely need some other strategy to overcome PARP resistance aside from just giving them PARP again as a single agent. We have many clinical trials looking at PARP combinations for these patients and so those are forthcoming and many of those are starting to report out and we may see some of that data as early as this year’s ASCO [American Society of Clinical Oncology annual meeting].
Transcript edited for clarity.