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Chemotherapy in Early-Stage Ovarian Cancer

Panelists: Bradley J. Monk, MD, FACS, FACOG, Arizona Oncology Practice of US Oncology; Oliver Dorigo, MD, PhD, Stanford University Medical Center; Thomas Herzog, MD, University of Cincinnati Cancer Institute; Kathleen Moore, MD, Stephenson Cancer Center; Leslie M. Randall, MD, MAS, University of California, Irvine
Published: Thursday, Aug 02, 2018



Transcript: 

Bradley J. Monk, MD, FACS, FACOG: Tom, assuming that it is an invasive cancer and not a borderline tumor, appreciating that some of these are endometrioid or clear cell—again, not germ cell—is chemotherapy always needed in early-stage ovarian cancer? If not, which patients can chemotherapy be avoided in?

Thomas Herzog, MD: I think there are a number of things to consider, and we’ve talked about some of them. What’s the histology? How many cycles of chemotherapy are you thinking about? We get into 3 cycles versus 6 cycles, for example. And then, what’s the stage? Importantly, I tend to treat most grade 2 tumors and beyond. I know it’s controversial, and I’ll be happy to hear what the rest of the panel does. But for me, I err on the side of treatment because I think that’s our best chance for cure—using it upfront. I would hate to think that the cancer came back because I didn’t treat. It’s been said twice already, but the need for thorough staging has to be emphasized here.

Bradley J. Monk, MD, FACS, FACOG: And that can be done laparoscopically.

Thomas Herzog, MD: Correct. The mode doesn’t matter, but it has to be done. That’s the important point. If you have a stage 1a, for example, or even 1b, grade 1 tumor, that tumor does not necessarily need chemotherapy. I usually omit chemotherapy in those patients.

Bradley J. Monk, MD, FACS, FACOG: And for the stage 1a or 1b, grade 3 tumor, or 1c, that patient does?

Thomas Herzog, MD: Absolutely. Pretty much anybody beyond what I just said.

Bradley J. Monk, MD, FACS, FACOG: But how about the grade 2 tumors? What you’ve said is, grade 1s don’t need it; grade 3s do. Or stage 1c. Do you treat 1a, grade 2 cancers with chemotherapy? Let’s say this is an endometrioid 1a, grade 2 tumor. Does she need 3 cycles of chemotherapy?

Oliver Dorigo, MD, PhD: In fully staged patients, I share Tom’s opinion. I’m still concerned about recurrence. We do know that recurrent ovarian cancer patients, regardless of what stage they were at initial diagnosis, are really difficult to cure.

Bradley J. Monk, MD, FACS, FACOG: Three or 6 doses?

Leslie M. Randall, MD, MAS: Three—early stage.

Bradley J. Monk, MD, FACS, FACOG: Three or 6 doses, Katie? For an endometrioid case. Let’s say its grade 2 or 3.

Kathleen Moore, MD: If I’m going to treat them, it’s shared decision making with the patient in a grade 2 scenario.

Bradley J. Monk, MD, FACS, FACOG: Thank you for that.

Kathleen Moore, MD: But for a grade 3 patient, I would do 3—for an endometrioid case.

Bradley J. Monk, MD, FACS, FACOG: There’s a whole philosophy out there that serous cancers, high-grade serous cancers, are almost never grade 1. Even though the staging, which you say is important, may suggest that metastases are not present, I think most of us would give 6 cycles for that high-grade serous tumor with the assumption being that the studies would suggest it.

Leslie M. Randall, MD, MAS: I think there’s a new important population, and those are the patients for whom microscopic cancers are found at the time of risk-reducing surgery.

Bradley J. Monk, MD, FACS, FACOG: OK, yes.

Leslie M. Randall, MD, MAS: And so, I don’t think we know yet. Again, the patient must be fully staged. Most of those patients will be high-grade serous tubal carcinomas. By standard guidelines, stage 1a, grade 3 will qualify for chemotherapy. There are some reports that suggest that these patients do well without chemotherapy, so that may be a special population. I don’t think we know enough yet to not treat them with chemotherapy.

Thomas Herzog, MD: If that were a close friend, would you recommend that—omitting the chemotherapy?

Leslie M. Randall, MD, MAS: Like I said, we don’t know enough to not recommend chemotherapy, so I think chemotherapy is still the standard recommendation.

Transcript Edited for Clarity 

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Transcript: 

Bradley J. Monk, MD, FACS, FACOG: Tom, assuming that it is an invasive cancer and not a borderline tumor, appreciating that some of these are endometrioid or clear cell—again, not germ cell—is chemotherapy always needed in early-stage ovarian cancer? If not, which patients can chemotherapy be avoided in?

Thomas Herzog, MD: I think there are a number of things to consider, and we’ve talked about some of them. What’s the histology? How many cycles of chemotherapy are you thinking about? We get into 3 cycles versus 6 cycles, for example. And then, what’s the stage? Importantly, I tend to treat most grade 2 tumors and beyond. I know it’s controversial, and I’ll be happy to hear what the rest of the panel does. But for me, I err on the side of treatment because I think that’s our best chance for cure—using it upfront. I would hate to think that the cancer came back because I didn’t treat. It’s been said twice already, but the need for thorough staging has to be emphasized here.

Bradley J. Monk, MD, FACS, FACOG: And that can be done laparoscopically.

Thomas Herzog, MD: Correct. The mode doesn’t matter, but it has to be done. That’s the important point. If you have a stage 1a, for example, or even 1b, grade 1 tumor, that tumor does not necessarily need chemotherapy. I usually omit chemotherapy in those patients.

Bradley J. Monk, MD, FACS, FACOG: And for the stage 1a or 1b, grade 3 tumor, or 1c, that patient does?

Thomas Herzog, MD: Absolutely. Pretty much anybody beyond what I just said.

Bradley J. Monk, MD, FACS, FACOG: But how about the grade 2 tumors? What you’ve said is, grade 1s don’t need it; grade 3s do. Or stage 1c. Do you treat 1a, grade 2 cancers with chemotherapy? Let’s say this is an endometrioid 1a, grade 2 tumor. Does she need 3 cycles of chemotherapy?

Oliver Dorigo, MD, PhD: In fully staged patients, I share Tom’s opinion. I’m still concerned about recurrence. We do know that recurrent ovarian cancer patients, regardless of what stage they were at initial diagnosis, are really difficult to cure.

Bradley J. Monk, MD, FACS, FACOG: Three or 6 doses?

Leslie M. Randall, MD, MAS: Three—early stage.

Bradley J. Monk, MD, FACS, FACOG: Three or 6 doses, Katie? For an endometrioid case. Let’s say its grade 2 or 3.

Kathleen Moore, MD: If I’m going to treat them, it’s shared decision making with the patient in a grade 2 scenario.

Bradley J. Monk, MD, FACS, FACOG: Thank you for that.

Kathleen Moore, MD: But for a grade 3 patient, I would do 3—for an endometrioid case.

Bradley J. Monk, MD, FACS, FACOG: There’s a whole philosophy out there that serous cancers, high-grade serous cancers, are almost never grade 1. Even though the staging, which you say is important, may suggest that metastases are not present, I think most of us would give 6 cycles for that high-grade serous tumor with the assumption being that the studies would suggest it.

Leslie M. Randall, MD, MAS: I think there’s a new important population, and those are the patients for whom microscopic cancers are found at the time of risk-reducing surgery.

Bradley J. Monk, MD, FACS, FACOG: OK, yes.

Leslie M. Randall, MD, MAS: And so, I don’t think we know yet. Again, the patient must be fully staged. Most of those patients will be high-grade serous tubal carcinomas. By standard guidelines, stage 1a, grade 3 will qualify for chemotherapy. There are some reports that suggest that these patients do well without chemotherapy, so that may be a special population. I don’t think we know enough yet to not treat them with chemotherapy.

Thomas Herzog, MD: If that were a close friend, would you recommend that—omitting the chemotherapy?

Leslie M. Randall, MD, MAS: Like I said, we don’t know enough to not recommend chemotherapy, so I think chemotherapy is still the standard recommendation.

Transcript Edited for Clarity 
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