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Therapy Selection in BRCA-Mutated 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: So, Dr. O’Malley says, “I’m going to use PARP inhibition in a platinum-sensitive relapse if she doesn’t have a biomarker because I can give bevacizumab later.” Do you use that same justification if she’s BRCA-mutated? In the germline BRCA patient, in the platinum-sensitive relapse, do you use more PARP or less? I actually use less in the platinum-sensitive relapse.

Matthew Powell, MD: Because you don’t want to help her more? Is that what you’re saying?

Bradley J. Monk, MD, FACS, FACOG: No, because I can give it to her later. When I look at a patient, I want to maximize her success. I want her to get all of my agents. I do not want her to suffer from chronic toxicities. And long-term bevacizumab—I’m not sure what you mean by the long-term toxicities with bevacizumab. Bevacizumab is tolerated very well, as long as you keep the blood pressure under control.

David O’Malley, MD: Cumulative toxicities.

Ursula Matulonis, MD: Voice changes.

Bradley J. Monk, MD, FACS, FACOG: Proteinuria.

David O’Malley, MD: Correct. And renal dysfunction.

Bradley J. Monk, MD, FACS, FACOG: So, do you use more PARP in sensitive-relapse with BRCA, or less?

Matthew Powell, MD: I use more.

Ursula Matulonis, MD: What was the question again?

Bradley J. Monk, MD, FACS, FACOG: In the platinum-sensitive relapse setting, do you use more PARP or less?

Ursula Matulonis, MD: For the patient who’s got a germline BRCA mutation, she’s going to have a terrific response to platinum and taxane. And, again, it is a discussion. If she is rendered as symptom-free with a platinum-doublet, I know that the PARP inhibitor is going to work. I know it’s going to work then, and we’re going to be following her. It may be a little later. She may say, “Look, I don’t really want the toxicities.” Or, “Yes, I want to do it because I’ve read about all of the trials.”

Bradley J. Monk, MD, FACS, FACOG: More or less, in the BRCA patients?

Shannon N. Westin, MD, MPH: Precision medicine.

David O’Malley, MD: I do think that gives you the option of watchful waiting, for following our serologic marker, and symptoms, and for utilizing the PARP once you see the disease become inactive again. You have that ability to treat, with that PARP, before they become symptomatic. I think that’s also an option.

Ursula Matulonis, MD: You really get a sense of that clinical progression of the patient. If that BRCA carrier normalizes down to 40 or something, then I would certainly consider using a PARP inhibitor as maintenance.

Transcript Edited for Clarity 

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Transcript: 

Bradley J. Monk, MD, FACS, FACOG: So, Dr. O’Malley says, “I’m going to use PARP inhibition in a platinum-sensitive relapse if she doesn’t have a biomarker because I can give bevacizumab later.” Do you use that same justification if she’s BRCA-mutated? In the germline BRCA patient, in the platinum-sensitive relapse, do you use more PARP or less? I actually use less in the platinum-sensitive relapse.

Matthew Powell, MD: Because you don’t want to help her more? Is that what you’re saying?

Bradley J. Monk, MD, FACS, FACOG: No, because I can give it to her later. When I look at a patient, I want to maximize her success. I want her to get all of my agents. I do not want her to suffer from chronic toxicities. And long-term bevacizumab—I’m not sure what you mean by the long-term toxicities with bevacizumab. Bevacizumab is tolerated very well, as long as you keep the blood pressure under control.

David O’Malley, MD: Cumulative toxicities.

Ursula Matulonis, MD: Voice changes.

Bradley J. Monk, MD, FACS, FACOG: Proteinuria.

David O’Malley, MD: Correct. And renal dysfunction.

Bradley J. Monk, MD, FACS, FACOG: So, do you use more PARP in sensitive-relapse with BRCA, or less?

Matthew Powell, MD: I use more.

Ursula Matulonis, MD: What was the question again?

Bradley J. Monk, MD, FACS, FACOG: In the platinum-sensitive relapse setting, do you use more PARP or less?

Ursula Matulonis, MD: For the patient who’s got a germline BRCA mutation, she’s going to have a terrific response to platinum and taxane. And, again, it is a discussion. If she is rendered as symptom-free with a platinum-doublet, I know that the PARP inhibitor is going to work. I know it’s going to work then, and we’re going to be following her. It may be a little later. She may say, “Look, I don’t really want the toxicities.” Or, “Yes, I want to do it because I’ve read about all of the trials.”

Bradley J. Monk, MD, FACS, FACOG: More or less, in the BRCA patients?

Shannon N. Westin, MD, MPH: Precision medicine.

David O’Malley, MD: I do think that gives you the option of watchful waiting, for following our serologic marker, and symptoms, and for utilizing the PARP once you see the disease become inactive again. You have that ability to treat, with that PARP, before they become symptomatic. I think that’s also an option.

Ursula Matulonis, MD: You really get a sense of that clinical progression of the patient. If that BRCA carrier normalizes down to 40 or something, then I would certainly consider using a PARP inhibitor as maintenance.

Transcript Edited for Clarity 
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