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Adopting Neoadjuvant Therapy into Ovarian Cancer

Panelists: Bradley J. Monk, MD, FACS, FACOG, University of Arizona, Creighton University, & Arizona Oncology Practice of US Oncology; Ursula Matulonis, MD, Dana-Farber Cancer Institute; David OMalley, MD, The Ohio State University; Matthew Powell, MD, Washington University; Shannon N. Westin, MD, MPH, MD Anderson Cancer Center
Published: Thursday, Apr 26, 2018



Transcript: 

Bradley J. Monk, MD, FACS, FACOG: Hello, and thank you for joining this OncLive® Peer Exchange®. Serous advanced ovarian cancers of the ovaries, fallopian tube, and peritoneum remain to be clinically challenging, with high mortality rates particularly in this setting of advanced disease. Although many of these cancers respond well to initial cytoreduction and chemotherapy, the vast majority will unfortunately recur and die. Therefore, it is paramount to understand optimal management of this disease and how to achieve the best outcomes for each individual patient in a personalized fashion.

In this OncLive® Peer Exchange® panel discussion, my colleagues and I will discuss the latest research surrounding the treatment of advanced ovarian cancer, and hopefully provide practical information on how to apply the latest findings into your clinical practice.

My name is Brad Monk. I’m a professor of gynecologic oncology at both the University of Arizona and Creighton University, in Phoenix, Arizona. I’m also part of the Arizona Oncology Practice, which is part of the US Oncology Network. Participating with me today are my very good friends and colleagues. I’d like to introduce you, first, to Ursula Matulonis, who is the director and program leader of gynecologic oncology at the Dana-Farber Cancer Institute. And then, David O’Malley, a professor of gynecologic oncology in the Department of Obstetrics and Gynecology at The Ohio State University. And, Matthew Powell, a director of gynecologic oncology at Washington University in St. Louis. Matt, thank you. And, Shannon Westin, an associate professor and director of early drug development at MD Anderson Cancer Center in Houston, Texas. Thank you for being with us. Let’s get started.

I think we understand the unmet need. I think we understand that there are 2 components—surgery and chemotherapy. Matt, what’s the role of surgery in newly-diagnosed ovarian cancer?

Matthew Powell, MD: I know you initially set this up with advanced cases, but we also want to identify those patients who present with early stage disease. And so, again, referral to a high-volume provider who takes care of these patients, most notably a gynecologic oncologist, is paramount. It allows us to do appropriate surgery and identify those patients who have early-stage disease, perhaps low-grade tumors that allow us to avoid chemotherapy when these patients are fully staged. When we mean fully staged, they’re having an omentectomy. They’re having lymph nodes done. We know that it’s not happening widely across communities. We think that’s very important—not only to help identify those who benefit from more aggressive therapies but also to determine appropriateness for holding back and treating appropriately when patients don’t need it.

Bradley J. Monk, MD, FACS, FACOG: Not every patient needs chemotherapy—particularly, those early stage patients who have been adequately operated on. But, debulking is another opportunity. Recently ASCO [American Society of Clinical Oncology] and the Society of Gynecologic Oncology (SGO) released a statement about frontline debulking. What do you think?

David O’Malley, MD: We really need to look at this very closely. All ovarian cancer patients, especially advanced stage patients, need to be assessed by gynecologic oncologist. Even if they had chemotherapy, they’re ultimately going to have surgery. Many patients can have primary surgery, and the goal of this primary surgery is to remove all disease—a complete cytoreduction for these patients. We may make the decision, based on the assessment prior to surgery, either on their performance status or the distribution of disease or other factors, for 3 cycles of chemotherapy. And then, interval debulking with the goal of once again removing all the disease, with 3 additional chemotherapy cycles afterwards. And again, it’s very important. There are combined statements by ASCO and SGO on this.

Bradley J. Monk, MD, FACS, FACOG: You’ve got to see a gynecologist before you start neoadjuvant therapy?

David O’Malley, MD: Correct.

Bradley J. Monk, MD, FACS, FACOG: How often do you think we use neoadjuvant therapy, Ursula? Is that common or uncommon? Or, does every patient basically start with upfront debulking?

Ursula Matulonis, MD: We’ve discussed the importance of the patient being seen by a gynecologic oncology surgeon. I do think that the rate and the usage of neoadjuvant chemotherapy is increasing with the realization that there are now several trials on this matter. In patients who have been assessed by a gynecologic surgeon, who are not deemed to be an operative candidate, upfront neoadjuvant chemotherapy renders a very similar progression-free survival and overall survival results. And, it’s safer. It improves patient outcomes. It reduces your surgical complication rate, hospital stays, etcetera.

Bradley J. Monk, MD, FACS, FACOG: It’s really been one of the breakthroughs—that chemotherapy can convert an inoperable patient to an operable patient. It has certainly changed my practice, I would say, in almost half of my cases.

Transcript Edited for Clarity

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Transcript: 

Bradley J. Monk, MD, FACS, FACOG: Hello, and thank you for joining this OncLive® Peer Exchange®. Serous advanced ovarian cancers of the ovaries, fallopian tube, and peritoneum remain to be clinically challenging, with high mortality rates particularly in this setting of advanced disease. Although many of these cancers respond well to initial cytoreduction and chemotherapy, the vast majority will unfortunately recur and die. Therefore, it is paramount to understand optimal management of this disease and how to achieve the best outcomes for each individual patient in a personalized fashion.

In this OncLive® Peer Exchange® panel discussion, my colleagues and I will discuss the latest research surrounding the treatment of advanced ovarian cancer, and hopefully provide practical information on how to apply the latest findings into your clinical practice.

My name is Brad Monk. I’m a professor of gynecologic oncology at both the University of Arizona and Creighton University, in Phoenix, Arizona. I’m also part of the Arizona Oncology Practice, which is part of the US Oncology Network. Participating with me today are my very good friends and colleagues. I’d like to introduce you, first, to Ursula Matulonis, who is the director and program leader of gynecologic oncology at the Dana-Farber Cancer Institute. And then, David O’Malley, a professor of gynecologic oncology in the Department of Obstetrics and Gynecology at The Ohio State University. And, Matthew Powell, a director of gynecologic oncology at Washington University in St. Louis. Matt, thank you. And, Shannon Westin, an associate professor and director of early drug development at MD Anderson Cancer Center in Houston, Texas. Thank you for being with us. Let’s get started.

I think we understand the unmet need. I think we understand that there are 2 components—surgery and chemotherapy. Matt, what’s the role of surgery in newly-diagnosed ovarian cancer?

Matthew Powell, MD: I know you initially set this up with advanced cases, but we also want to identify those patients who present with early stage disease. And so, again, referral to a high-volume provider who takes care of these patients, most notably a gynecologic oncologist, is paramount. It allows us to do appropriate surgery and identify those patients who have early-stage disease, perhaps low-grade tumors that allow us to avoid chemotherapy when these patients are fully staged. When we mean fully staged, they’re having an omentectomy. They’re having lymph nodes done. We know that it’s not happening widely across communities. We think that’s very important—not only to help identify those who benefit from more aggressive therapies but also to determine appropriateness for holding back and treating appropriately when patients don’t need it.

Bradley J. Monk, MD, FACS, FACOG: Not every patient needs chemotherapy—particularly, those early stage patients who have been adequately operated on. But, debulking is another opportunity. Recently ASCO [American Society of Clinical Oncology] and the Society of Gynecologic Oncology (SGO) released a statement about frontline debulking. What do you think?

David O’Malley, MD: We really need to look at this very closely. All ovarian cancer patients, especially advanced stage patients, need to be assessed by gynecologic oncologist. Even if they had chemotherapy, they’re ultimately going to have surgery. Many patients can have primary surgery, and the goal of this primary surgery is to remove all disease—a complete cytoreduction for these patients. We may make the decision, based on the assessment prior to surgery, either on their performance status or the distribution of disease or other factors, for 3 cycles of chemotherapy. And then, interval debulking with the goal of once again removing all the disease, with 3 additional chemotherapy cycles afterwards. And again, it’s very important. There are combined statements by ASCO and SGO on this.

Bradley J. Monk, MD, FACS, FACOG: You’ve got to see a gynecologist before you start neoadjuvant therapy?

David O’Malley, MD: Correct.

Bradley J. Monk, MD, FACS, FACOG: How often do you think we use neoadjuvant therapy, Ursula? Is that common or uncommon? Or, does every patient basically start with upfront debulking?

Ursula Matulonis, MD: We’ve discussed the importance of the patient being seen by a gynecologic oncology surgeon. I do think that the rate and the usage of neoadjuvant chemotherapy is increasing with the realization that there are now several trials on this matter. In patients who have been assessed by a gynecologic surgeon, who are not deemed to be an operative candidate, upfront neoadjuvant chemotherapy renders a very similar progression-free survival and overall survival results. And, it’s safer. It improves patient outcomes. It reduces your surgical complication rate, hospital stays, etcetera.

Bradley J. Monk, MD, FACS, FACOG: It’s really been one of the breakthroughs—that chemotherapy can convert an inoperable patient to an operable patient. It has certainly changed my practice, I would say, in almost half of my cases.

Transcript Edited for Clarity
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