Chad Hamilton, MD: What treatment would you choose if the progression-free interval was less than 6 months? I’m getting to a tough-to-treat group here. What if the patient was BRCA wild type and HR [homologous recombination]-proficient? Anybody want to take a stab at that one?
Shannon Westin, MD: Per so-called platinum-resistant disease, we’re certainly moving away from that and looking at what the platinum-free interval is. For anything less than 6 months, I would move on from platinum and pursue something consistent with the AURELIA study: chemotherapy with bevacizumab. I like to use weekly paclitaxel quite a bit here; we get a lot of activity, but pegylated liposomal doxorubicin, topotecan, or even gemcitabine are reasonable in combination with bevacizumab.
Thomas C. Krivak, MD: I completely agree with that. Platinum sensitivity is a biomarker for PARP inhibitor sensitivity, so I would have moved into bevacizumab for sure and other chemotherapy combinations.
Shannon Westin, MD: Or a clinical trial, right, Tom?
Thomas C. Krivak, MD: Yes, a clinical trial.
Chad Hamilton, MD: Correct answer, Dr Westin.
Shannon Westin, MD: If the patient was wild type and HR-proficient, and if it’s a platinum-free interval of less than 6 months, then it’s the same answer. If it’s for our prior patient who was in a secondary maintenance setting after response to a platinum-based therapy, you can still use a PARP inhibitor in that patient population, but just like up front, you’ve got to be mindful of what your benefit is going to be and make sure they know that too.
Thomas C. Krivak, MD: I would definitely not do surgery. This would be palliation.
Shannon Westin, MD: That’s right.
Thomas C. Krivak, MD: I said I would do secondary debulking; I would rescind that comment at this point.
Chad Hamilton, MD: Alright. Shannon touched on this: a trial guiding how she may approach this patient. This trial assessed bevacizumab in combination with various chemotherapies: liposomal doxorubicin, weekly Taxol [paclitaxel] or topotecan versus chemotherapy alone in platinum-resistant ovarian cancer. For patients receiving the bevacizumab versus bevacizumab with chemotherapy combo, the primary end point being progression-free survival, was 6.7 months versus 3.4 months. The median overall survival was 16.6 months with the bevacizumab arm versus 13 months in the chemotherapy-alone arm. A progression-free survival benefit; it’s tough to meet that overall survival threshold.
This is an exploratory analysis demonstrating the difference between arms, but based on this trial, all are reasonable alternatives for this difficult-to-treat scenario. You tailor the chemotherapy plus bevacizumab and which cytotoxic you’re going to use based on the patient’s performance status and things like that. I don’t intend this slide to say that Taxol [paclitaxel] is better than the others. This is an exploratory, so you need to take this while considering to a large degree which cytotoxic the patient is going to tolerate best in this palliative setting.
Transcript edited for clarity.