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Maintenance Therapy for Recurrent Advanced Ovarian Cancer

Panelists: Bradley J. Monk, MD, FACS, FACOG, University of Arizona and Creighton University; Michael J. Birrer, MD, PhD The University of Alabama at Birmingham; Ursula A. Matulonis, MD, Harvard Medical School
Published: Thursday, Jan 03, 2019



Transcript: 

Bradley J. Monk, MD: So, most of the patients [who] we see in second line, who get a platinum doublet, [are] bevacizumab naïve because the FDA approval just happened in June 2018. So that means that patient, in the second line, is going to get a platinum doublet, and we [talk] about the options. You’re going to have to make a decision: bevacizumab or a PARP [poly (ADP-ribose) polymerase] inhibitor. And I hope that’s the decision—I hope it’s not the decision of bevacizumab, PARP, or observation. I think if we learn anything, [for] the patient who’s probably going to die, [if we] say, “Go home; good luck; we’ll check your CA 125 in 3 months,” [that] is not the way to treat our patients—the paradigm has evolved. And because maintenance therapy, as I said, is now efficacious and tolerable, what do you make of that?

Michael J. Birrer, MD, PhD: Can I just interject on that? I think you know that this data [are] not published, but [they are] public, so I can say it. Which is [that], at present, the number of patients who are eligible for maintenance are getting it; [this] is somewhere around 20% to 30%.

Bradley J. Monk, MD: It blows my mind. And the NCCN [National Comprehensive Cancer Network Clinical Practice] Guidelines [in Oncology] seem to say you’ve got 3 options. After responding to platinum second line, you’ve got observation, bevacizumab, or PARP, and again, all 3 PARP inhibitors are approved in that space, but there’s no prioritization. And I’m here to tell you that there is a prioritization.

Ursula A. Matulonis, MD: Yes.

Bradley J. Monk, MD: And the prioritization, I’m not going to tell you bevacizumab versus PARP. But [what] I’m going to tell you is bevacizumab or PARP versus nothing.

Ursula A. Matulonis, MD: No, you’re right. And so I think, in terms of decision making, as you just said, Brad, it’s really making that decision up front. So it’s making that decision: Is [the patient] a bevacizumab candidate or not?

Bradley J. Monk, MD: How do you decide?

Ursula A. Matulonis, MD: You decide based upon the level of disease. The issue around bevacizumab is that, yes, it prolongs progression-free survival [PFS], [and] maybe overall survival [OS], a little bit, but their overall response rate is going to be higher. So that patient is more symptomatic but, on the other hand, not quite…symptomatic enough to have a bowel obstruction or an impending bowel obstruction. I would certainly think about [this patient] for bevacizumab because you need a response now.

Bradley J. Monk, MD: Let me address that. At this meeting, ESMO [European Society of Medical Oncology] 2018 [Congress], the new ESMO [Clinical Practice Guidelines for] ovarian cancer…were launched, and [they are] exactly what you said. And they’re trying—they had recognized that observation is a bad idea. But they say, [for] the more symptomatic patient, that the triaging to bevacizumab is preferred. I like that, and that’s what the guidelines have said.

Michael J. Birrer, MD, PhD: Well, that’s certainly true for ascites in issues like this.

Bradley J. Monk, MD: Yeah, that’s the whole point.

Michael J. Birrer, MD, PhD: What I find interesting about the discussion [is that] it applied to frontline also. I think concerning that, the hesitation to use bevacizumab [is] because it’s only PFS versus OS, and not different [from] PARPs. There’s not a lot of OS data [with] PARPs.

Ursula A. Matulonis, MD: Not yet. But we do have that data available for bevacizumab. We don’t have that data yet for PARP inhibitors.

Transcript Edited for Clarity

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Transcript: 

Bradley J. Monk, MD: So, most of the patients [who] we see in second line, who get a platinum doublet, [are] bevacizumab naïve because the FDA approval just happened in June 2018. So that means that patient, in the second line, is going to get a platinum doublet, and we [talk] about the options. You’re going to have to make a decision: bevacizumab or a PARP [poly (ADP-ribose) polymerase] inhibitor. And I hope that’s the decision—I hope it’s not the decision of bevacizumab, PARP, or observation. I think if we learn anything, [for] the patient who’s probably going to die, [if we] say, “Go home; good luck; we’ll check your CA 125 in 3 months,” [that] is not the way to treat our patients—the paradigm has evolved. And because maintenance therapy, as I said, is now efficacious and tolerable, what do you make of that?

Michael J. Birrer, MD, PhD: Can I just interject on that? I think you know that this data [are] not published, but [they are] public, so I can say it. Which is [that], at present, the number of patients who are eligible for maintenance are getting it; [this] is somewhere around 20% to 30%.

Bradley J. Monk, MD: It blows my mind. And the NCCN [National Comprehensive Cancer Network Clinical Practice] Guidelines [in Oncology] seem to say you’ve got 3 options. After responding to platinum second line, you’ve got observation, bevacizumab, or PARP, and again, all 3 PARP inhibitors are approved in that space, but there’s no prioritization. And I’m here to tell you that there is a prioritization.

Ursula A. Matulonis, MD: Yes.

Bradley J. Monk, MD: And the prioritization, I’m not going to tell you bevacizumab versus PARP. But [what] I’m going to tell you is bevacizumab or PARP versus nothing.

Ursula A. Matulonis, MD: No, you’re right. And so I think, in terms of decision making, as you just said, Brad, it’s really making that decision up front. So it’s making that decision: Is [the patient] a bevacizumab candidate or not?

Bradley J. Monk, MD: How do you decide?

Ursula A. Matulonis, MD: You decide based upon the level of disease. The issue around bevacizumab is that, yes, it prolongs progression-free survival [PFS], [and] maybe overall survival [OS], a little bit, but their overall response rate is going to be higher. So that patient is more symptomatic but, on the other hand, not quite…symptomatic enough to have a bowel obstruction or an impending bowel obstruction. I would certainly think about [this patient] for bevacizumab because you need a response now.

Bradley J. Monk, MD: Let me address that. At this meeting, ESMO [European Society of Medical Oncology] 2018 [Congress], the new ESMO [Clinical Practice Guidelines for] ovarian cancer…were launched, and [they are] exactly what you said. And they’re trying—they had recognized that observation is a bad idea. But they say, [for] the more symptomatic patient, that the triaging to bevacizumab is preferred. I like that, and that’s what the guidelines have said.

Michael J. Birrer, MD, PhD: Well, that’s certainly true for ascites in issues like this.

Bradley J. Monk, MD: Yeah, that’s the whole point.

Michael J. Birrer, MD, PhD: What I find interesting about the discussion [is that] it applied to frontline also. I think concerning that, the hesitation to use bevacizumab [is] because it’s only PFS versus OS, and not different [from] PARPs. There’s not a lot of OS data [with] PARPs.

Ursula A. Matulonis, MD: Not yet. But we do have that data available for bevacizumab. We don’t have that data yet for PARP inhibitors.

Transcript Edited for Clarity
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