Risk-Reducing Surgery in Epithelial Ovarian Cancer

Transcript:Bradley J. Monk, MD, FACOG, FACS: Hello, and thank you for joining this OncLive Peer Exchange® program regarding evolving concepts in the management of advanced ovarian cancer.

We continue to make progress in refining new treatment approaches to advanced epithelial ovarian cancer, tubal cancer, and peritoneal cancer, which we collectively call ovarian cancer. In today’s OncLive Peer Exchange® discussion, I am joined by a panel of experts in the field of gynecologic oncology. We will discuss evolving aspects of treatment and will provide practical perspectives on the latest data from the 50th 2019 SGO [Society of Gynecologic Oncology] Annual Meeting.

My name is Brad Monk. I’m a professor in the division of gynecologic oncology at both the University of Arizona and Creighton University in Phoenix. I’m also the medical director of the US Oncology Research Network located in, again, Phoenix, Arizona.

Participating today on our distinguished panel are: Dr Kathleen Moore, who I know as Katie. She’s an associate professor in the section of gynecologic oncology at the University of Oklahoma. She’s the director of a phase I program, from Oklahoma City. Thanks, Katie, for joining us.

Kathleen N. Moore, MD: Thanks for having me.

Bradley J. Monk, MD, FACOG, FACS: And then Elena Ratner, an associate professor of obstetrics-gynecology and a cochief in the section of gynecologic oncology at Yale University, around the corner in New Haven, Connecticut. Thank you, Elena.

Elena S. Ratner, MD: Thank you.

Bradley J. Monk, MD, FACOG, FACS: And then finally, Dr Brian Slomovitz, who’s a professor and the chief of gynecologic oncology at the Sylvester Comprehensive Cancer Center at the University of Miami, in Miami, Florida. Welcome, Brian.

Brian M. Slomovitz, MD: Thanks for having me, Brad.

Bradley J. Monk, MD, FACOG, FACS: And thank you for joining us. We have a lot of exciting things to cover today. Let’s get started with surgery. Surgery still has a role in ovarian cancer, and the surgical management of ovarian cancer has an intersection with the pathogenesis of epithelial ovarian cancer. Elena, we’re going to begin with you. Tell us about the pathogenesis of epithelial ovarian cancer.

Elena S. Ratner, MD: Brad, that’s a great question to begin with. In the old days, like 5 years ago, we used to believe that ovarian cancer happened because of ovulation and believed this cancer genesis occurred every time the woman ovulated. We more recently now believe that a lot of these cancers actually originate in the fallopian tubes. There’s a lot of evidence for that. Part of it is the serous tubal intraepithelial carcinoma [STIC] that we sometimes find in the tubes as we take them out. The big component, of course, of ovarian cancer—just like any cancer—is genetics. We know that a huge subset, or proportionally a large subset of these cancers have a deleterious mutation that brings on this cancer—BRCA1, BRCA2. But there are way more mutations than that. And this, of course, now brings out this conversation. We know that early detection of ovarian cancer is challenging, so the key is prevention, and not necessarily even early detection. So the key that comes up: Who are the women at risk? And if we know that they’re at risk, what should we do about it? That’s why the conversation recently came up about removing fallopian tubes before you would remove the ovaries in these women who are at increased risk.

Bradley J. Monk, MD, FACOG, FACS: I love it. STIC—serous tubal intraepithelial carcinoma—where the p53 molecular signatures occur and, ultimately, these fallopian tube cancers are known as ovarian or even primary peritoneal.

Elena S. Ratner, MD: That’s right.

Bradley J. Monk, MD, FACOG, FACS: And she mentioned removing the fallopian tubes. I love acronyms. ISDO. What does ISDO stand for, and how is that integrated? And what were the new data presented at the SGO Annual Meeting?

Brian M. Slomovitz, MD: Thanks, Brad. I think the important point she was alluding to is that the best way to treat ovarian cancer is to prevent ovarian cancer. So what we’re doing: We’ve identified a subgroup of women who are at high risk for developing the disease. Traditionally, we’ve known that the best way to prevent cancer in that group of women is, when they’re done having children, go in and take out the tubes and the ovaries. What really just came out of the meeting last week in Hawaii were data presented from ISDO, or interval salpingectomy with delayed oophorectomy.

Bradley J. Monk, MD, FACOG, FACS: I love it.

Brian M. Slomovitz, MD: So what they’re doing, knowing that most of these cancers are coming from the tubes, is going in first and taking out the tube. Let the woman live with their ovaries, produce hormones, and not interfere—not put them into a premature menopause. And then go back later on and take out the ovary.

Bradley J. Monk, MD, FACOG, FACS: With the intention of preserving their hormonal function and improving quality of life, right?

Brian M. Slomovitz, MD: Exactly. And what they found, based on some of the preliminary findings—this is still experimental and needs to be done on a clinical trial, so we’re not encouraging providers to go out there and do this until we get survival data, which will still take some time—is that those women who had their tubes and ovaries taken out had worsening menopausal symptoms and also a higher rate of regret. So again, we’re not sure what to make of the data yet, and I’m sure there are going to be a lot more data that need to be collected before we change the standard of care. But it is important, No 1, that we need to prevent cancers. That’s by early surgery, and we need to figure out the best way to do that.

Bradley J. Monk, MD, FACOG, FACS: Elena, you mentioned risk and BRCA1 and BRCA2. Obviously, the risk of ovarian cancer is lower in the BRCA2 cohort. Do you endorse that it’s OK to delay risk-reducing surgery to a later age in the BRCA2 patients, or do you think BRCA2 and BRCA1 need the risk-reducing surgery at about the same age?

Elena S. Ratner, MD: I think this is going to be a big part of our conversation today. I think a big part of our conversation today is going to be on personalized care. That’s going to apply to this. It’s going to apply to the treatments we’re going to talk about. It’s going to apply to targeted therapies. So I think it’s a very personalized decision. Even to have this discussion now about taking out the fallopian tubes and leaving the ovaries, and potentially leaving the women with their hormones for longer in life is an amazing advance. But yes, traditionally we believe that for women with BRCA2 mutations, their ovaries can be kept in place longer. Whereas with BRCA1, you would take it out at a bit younger age. But of course, the big part of it, again, depends on the patient and on her family history. If this family history revealed somebody who had ovarian cancer at a younger age in life, that, of course, would not apply. Everything is very, very truly personalized.

Transcript Edited for Clarity