Expert Approaches for Treating Recurrent Ovarian Cancer

Bradley Monk, MD, FACOG, FACS: Hello, and welcome to this OncLive® Peer Exchange® entitled, “Practical Implications for New Treatment Strategies in Advanced Ovarian Cancer.” I’d like to focus on recurrent ovarian cancer, although there’s great hope for cure in newly diagnosed advanced ovarian cancer. We have new FDA approvals in the frontline setting with niraparib in all-comers as per April 29th approval of PRIMA, and as per the FDA approval of PAOLA-1 on May 8th with olaparib and bevacizumab in the HRD [homologous recombination deficient] cohorts. It’s difficult to say but still true that most of our patients develop recurrence.

The first agent approved in recurrent ovarian cancer was bevacizumab. This was November 14, 2014: AURELIA. This was a small step forward in platinum-resistant recurrent ovarian cancer in second and third line with a hazard ratio of 0.38 and only a 3-month improvement in progression-free survival [PFS].

Then in December of 2016, we got a platinum-sensitive option, which was a little better. It had 2 chemotherapy backbones: carboplatin-gemcitabine a la OCEANS and carboplatin-paclitaxel a la GOG-0213. OCEANS showed a bit better improvement in progression-free survival with a 4-month improvement; GOG-0213 had a 5-month improvement in survival. That was good, but it’s definitely not enough. Most of us prefer bevacizumab in the frontline setting. Leslie, I’m going to ask you, what percentage of patients with ovarian cancer do you think get bevacizumab at some point?

Leslie Randall, MD, FACOG: Hopefully most. It being frontline, platinum-sensitive, platinum-resistant, and being an active drug, I would hope that most of them, if not all of them, receive bevacizumab at some point.

Bradley Monk, MD, FACOG, FACS: In the platinum-resistant setting, Shannon, all else being equal, what’s your preferred chemotherapy backbone of those 3 AURELIA options?

Shannon N. Westin, MD, MPH, FACOG: I tend to lean toward the weekly paclitaxel. We saw in the laboratory that there’s something about the way those 2 drugs interact that we get even more bonus on antiangiogenic activity. The patients tolerate it well too.

Bradley Monk, MD, FACOG, FACS: The 2 approvals, Matt, in the United States, as you know are carboplatin-gemcitabine, carboplatin-paclitaxel in the sensitive space. There’s a lot of discussion about carboplatin-PLD [pegylated liposomal doxorubicin] as a third option. What’s your go-to regimen in the platinum-sensitive space if bevacizumab is a part of that?

Matthew Powell, MD: We’re looking at patient factors to help drive that, the advantage of the PLD [pegylated liposomal doxorubicin] regimen is clearly the Q4 every 4-week dosing schedule, so sometimes that’s driving it. Looking at the quality of the level of the data from GOG-0213, you have an OS [overall survival] benefit with giving Taxol [paclitaxel] again, so carboplatin/Taxol [paclitaxel] plus bevacizumab. That’s my go-to regimen when I want that additional bar beyond PFS. That’s strong; it’s right at the physical cutoff, but it is positive with OS.

Bradley Monk, MD, FACOG, FACS: Shannon said it nicely that there is some special interaction with paclitaxel and bevacizumab, whether it’s cervical cancer, platinum-resistant or platinum-sensitive ovarian cancer.

Matthew Powell, MD: You hate to make neuropathy worse, but there are a lot of tricks that we have to try to minimize that, alternate taxanes and things. We can get patients through this. They’re just not so excited about losing their hair again, so it can be a lengthy discussion.

Transcript edited for clarity.