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Ovarian Cancer: Making Treatment Plans Together

Insights From: Angeles Alvarez Secord, MD, Duke University Medical Center; Michelle Berke
Published: Tuesday, Jan 02, 2018



Transcript: 

Angeles Alvarez Secord, MD: So, Michelle, we went through your initial treatment course really quickly. But I want to back up a little bit and just review something that is important for our patients to consider. When you’re making those decisions about the treatment plan, we made those together, but I was really giving my recommendations. I gave you probably 5 different choices to begin with. So, currently according to guidelines, there are a lot of different ways you can treat ovarian cancer. IV chemotherapy is the cornerstone of treatment and you were treated with paclitaxel/carboplatinum/bevacizumab, which is an option. Another option is just the chemotherapy alone every 3 weeks. Or you can do this dose dense report where you do the paclitaxel weekly, you don’t have a break. You can interject other drugs other than paclitaxel, such as docetaxel. Some individuals might use liposomal doxorubicin.

Michelle Berke: I’ve heard of that.

Angeles Alvarez Secord, MD: And then we talked a little bit about the intraperitoneal chemotherapy and which patients are appropriate candidates. So, we didn’t do intraperitoneal chemotherapy at the beginning because you weren’t what’s called optimally debulked. But after the chemotherapy and that second surgery, then you were optimally debulked.

Michelle Berke: That’s when you put the port…

Angeles Alvarez Secord, MD: Exactly. But that was confusing, right? So, it’s important for patients to know about their options. That was a long decision, discussion, we had in the clinic. It was probably 30 to 45 minutes. And then we talked on the phone, too.

Michelle Berke: Yes, and I went home and looked everything up online just to see what would be best for me.

Angeles Alvarez Secord, MD: Right.

Michelle Berke: And then your recommendations were spot on.

Angeles Alvarez Secord, MD: So, it’s all the different treatment options, what’s right for you as a patient. Like I mentioned before, you were young and healthy, otherwise really fit. Somebody who is not as fit may not be as good a candidate for surgery. Then you need to think about other options like chemotherapy first to get them stronger, get their cancer under control, and then the surgery.

Michelle Berke: And then go back, yes.

Angeles Alvarez Secord, MD: Right. And you know, that’s a big, big question. Do you do the chemotherapy first then the surgery and more chemotherapy? Or do you do the primary debulking surgery first? And at Duke, how we like to make that decision is the laparoscopy procedure that we did in your situation. And then we said, “OK, well the reason, even though we can’t remember all the reasons we were going for it, was because you were so symptomatic.” So, that’s a really important thing that patients should ask their doctors: Which one’s better for me in terms of the sequence? Is it chemotherapy first or surgery first, and how do we go about this?

Any questions that you had in terms of that whole treatment process? What were your biggest concerns?

Michelle Berke: I think my biggest concern is when I start hearing statistics. You know, they were disconcerting to me. Like you mentioned Avastin. So, people with Avastin, statistically, how much longer do they live with it as posed to without it?

Angeles Alvarez Secord, MD: So, you may not remember me saying, but my classic line there is, you have to be careful how you evaluate those studies because it’s a number. And the patients who were on that study, they might not be just like you. Some of the other studies that were done with Avastin, they were done in women who had different types of disease. Maybe it was more advanced than in your situation, maybe there’s something different around the patient. So, I take those numbers with the grain of salt. What you may remember I presented then to you, don’t think about that. You as an individual, your story is going to be your story, so we don’t know where things are going to be on that question.

Michelle Berke: Everybody is so different.

Angeles Alvarez Secord, MD: Right. And remember, that’s a median number. So, they give you this number that’s in the middle but there’s a bell-shaped curve, right? And you could be on this long side of the curve and that’s what you aim for.

Michelle Berke: I like that, I like that curve.

Angeles Alvarez Secord, MD: Right. So, I think that’s important to know.

Michelle Berke: OK.

Angeles Alvarez Secord, MD: And it’s hard to bring up those questions about prognosis. Some doctors have a hard time bringing it up and they wait for the patient to give the cue. But the patients really don’t know how to bring up those questions either.

Michelle Berke: That’s a hard question, yes, because doctors don’t really know.

Angeles Alvarez Secord, MD: And that’s another thing with ovarian cancer. Some types of cancers, like pancreatic cancer for instance, it’s not as good of a prognosis, unless for those patients it’s a tighter period of time in terms of how long they’re going to survive. But ovarian cancer, you can have women surviving anywhere from 24 months up to 10 or more years. It really has to do with their own tumor biology as well as their own medical issues that make that determinant and how well they respond to chemotherapy.

Transcript Edited for Clarity 
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Transcript: 

Angeles Alvarez Secord, MD: So, Michelle, we went through your initial treatment course really quickly. But I want to back up a little bit and just review something that is important for our patients to consider. When you’re making those decisions about the treatment plan, we made those together, but I was really giving my recommendations. I gave you probably 5 different choices to begin with. So, currently according to guidelines, there are a lot of different ways you can treat ovarian cancer. IV chemotherapy is the cornerstone of treatment and you were treated with paclitaxel/carboplatinum/bevacizumab, which is an option. Another option is just the chemotherapy alone every 3 weeks. Or you can do this dose dense report where you do the paclitaxel weekly, you don’t have a break. You can interject other drugs other than paclitaxel, such as docetaxel. Some individuals might use liposomal doxorubicin.

Michelle Berke: I’ve heard of that.

Angeles Alvarez Secord, MD: And then we talked a little bit about the intraperitoneal chemotherapy and which patients are appropriate candidates. So, we didn’t do intraperitoneal chemotherapy at the beginning because you weren’t what’s called optimally debulked. But after the chemotherapy and that second surgery, then you were optimally debulked.

Michelle Berke: That’s when you put the port…

Angeles Alvarez Secord, MD: Exactly. But that was confusing, right? So, it’s important for patients to know about their options. That was a long decision, discussion, we had in the clinic. It was probably 30 to 45 minutes. And then we talked on the phone, too.

Michelle Berke: Yes, and I went home and looked everything up online just to see what would be best for me.

Angeles Alvarez Secord, MD: Right.

Michelle Berke: And then your recommendations were spot on.

Angeles Alvarez Secord, MD: So, it’s all the different treatment options, what’s right for you as a patient. Like I mentioned before, you were young and healthy, otherwise really fit. Somebody who is not as fit may not be as good a candidate for surgery. Then you need to think about other options like chemotherapy first to get them stronger, get their cancer under control, and then the surgery.

Michelle Berke: And then go back, yes.

Angeles Alvarez Secord, MD: Right. And you know, that’s a big, big question. Do you do the chemotherapy first then the surgery and more chemotherapy? Or do you do the primary debulking surgery first? And at Duke, how we like to make that decision is the laparoscopy procedure that we did in your situation. And then we said, “OK, well the reason, even though we can’t remember all the reasons we were going for it, was because you were so symptomatic.” So, that’s a really important thing that patients should ask their doctors: Which one’s better for me in terms of the sequence? Is it chemotherapy first or surgery first, and how do we go about this?

Any questions that you had in terms of that whole treatment process? What were your biggest concerns?

Michelle Berke: I think my biggest concern is when I start hearing statistics. You know, they were disconcerting to me. Like you mentioned Avastin. So, people with Avastin, statistically, how much longer do they live with it as posed to without it?

Angeles Alvarez Secord, MD: So, you may not remember me saying, but my classic line there is, you have to be careful how you evaluate those studies because it’s a number. And the patients who were on that study, they might not be just like you. Some of the other studies that were done with Avastin, they were done in women who had different types of disease. Maybe it was more advanced than in your situation, maybe there’s something different around the patient. So, I take those numbers with the grain of salt. What you may remember I presented then to you, don’t think about that. You as an individual, your story is going to be your story, so we don’t know where things are going to be on that question.

Michelle Berke: Everybody is so different.

Angeles Alvarez Secord, MD: Right. And remember, that’s a median number. So, they give you this number that’s in the middle but there’s a bell-shaped curve, right? And you could be on this long side of the curve and that’s what you aim for.

Michelle Berke: I like that, I like that curve.

Angeles Alvarez Secord, MD: Right. So, I think that’s important to know.

Michelle Berke: OK.

Angeles Alvarez Secord, MD: And it’s hard to bring up those questions about prognosis. Some doctors have a hard time bringing it up and they wait for the patient to give the cue. But the patients really don’t know how to bring up those questions either.

Michelle Berke: That’s a hard question, yes, because doctors don’t really know.

Angeles Alvarez Secord, MD: And that’s another thing with ovarian cancer. Some types of cancers, like pancreatic cancer for instance, it’s not as good of a prognosis, unless for those patients it’s a tighter period of time in terms of how long they’re going to survive. But ovarian cancer, you can have women surviving anywhere from 24 months up to 10 or more years. It really has to do with their own tumor biology as well as their own medical issues that make that determinant and how well they respond to chemotherapy.

Transcript Edited for Clarity 
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