Ovarian Cancer: Evolving Concepts Around Systemic Therapy - Episode 1
Bradley J. Monk, MD: Hello, and welcome to this OncLive® Peer Exchange® titled, “Ovarian Cancer: Evolving Concepts Around Systemic Therapy.” My name is Brad Monk. I’m a gynecologic oncologist from Phoenix, Arizona, at both the University of Arizona and Creighton University, as well as The US Oncology Network. Joining me today in this discussion are my colleagues: Tom Herzog, from the University of Cincinnati Cancer Institute in Cincinnati, Ohio. Welcome, Tom.
Thomas J. Herzog, MD: Brad, it’s a pleasure to be with you today, and I look forward to a great discussion. Thanks for having me.
Bradley J. Monk, MD: Dr Tom Krivak from the University of Pittsburgh Medical Center and Allegheny Health Network in Pittsburgh, Pennsylvania. Go Steelers! Thank you, Tommy.
Thomas C. Krivak, MD: Thanks for having me here, I’m looking forward to a great discussion.
Bradley J. Monk, MD: Dr Sharyn Lewin from Holy Name Medical Center in Teaneck, New Jersey. Thank you, Sharyn, for joining us.
Sharyn N. Lewin, MD: Thank you for having me.
Bradley J. Monk, MD: And Dr Katie Moore from the Stephenson Cancer Center at University of Oklahoma in Oklahoma City, Oklahoma. I want to recognize Dr Moore for her contribution to the Society of Gynecologic Oncology [SGO] as the program chair this year. She was able to seamlessly transition from an in-person meeting to a virtual meeting. I thank you for that. The scientific exchange was very exciting and informative, and that’s 1 of the reasons we’re here today. We’re here today to talk about new presentations, new indications, new studies, new research, and innovation from the Society of Gynecologic Oncology 2020 Annual Meeting.
We’re here because of 2 indications in ovarian cancer beyond BRCA. The PRIMA study was published in the New England Journal of Medicine in 2019 and presented at ESMO [European Society for Medical Oncology Congress] 2019. We’re going to take a deep dive into what PRIMA and maintenance niraparib means to you and your patients. PAOLA-1 was also presented in Madrid at ESMO 2019 and published in the New England Journal in 2019. We’ll discuss what that study means to you, starting with bevacizumab and bevacizumab maintenance therapy but adding olaparib to it in the maintenance space. Hopefully when you’re done here, you will know what you missed at the SGO meeting if you did miss it. If you didn’t miss it, we’ll hopefully add some context. We’ll discuss some opportunities with these new approvals.
I’m going to begin here by talking about bevacizumab. Bevacizumab was the first targeted therapy to be approved in 2014. We’re going to begin by talking about first-line treatment. Bevacizumab was approved in June 2018 as first-line therapy. Tom Krivak, tell us about GOG-0218 and how that led to FDA approval.
Thomas C. Krivak, MD: GOG-0218 was a large randomized trial of about 1800 or 1900 patients with 3 arms. It was designed by you and Dr Robert Burger a long time ago when we were learning about targeted therapies, and it’s undergone many publications. The most recent publication was the final publication looking at overall survival. Comparing all 3 groups, there was no difference in the overall survival. However, when we look at this publication, there are a couple of things that are really important to note. The stage IV group did show an improvement in overall survival of 10 months: 33 months versus 43 months in the patients who received bevacizumab with bevacizumab maintenance. I also think it’s really important that as we go through these discussions, we’re going to be talking about HRD [homologous recombination deficiency] and some other biomarkers.
The trial and this publication did try to look at HRR [homologous recombination repair] genes, but it was only in 1200 of the patients. But to me, I think that as we take some small steps with molecular medicine, we’re going to need some of these trials to look at how this may affect patient selection for molecular-targeted therapy for up-front treatment. The label with the PFS [progression-free survival] improvement of 6 months while receiving maintenance bevacizumab is what it was approved on, and the overall survival final paper showed that there was no improvement in overall survival. I think that’s the summary for this paper at this time.
Bradley J. Monk, MD: It’s been an important step forward. It was not a big step, but it was an initial step. Six months of progression-free survival when bevacizumab is added to chemotherapy and in maintenance for a total of 15 months. In some people’s minds this is impactful, certainly in the high-risk subgroup. It’s most important today, though, because it’s a path toward other treatments. We’re adding PARP inhibitors to bevacizumab, and if you don’t start bevacizumab, you can’t add it to it. There will be a study imminently, which we’ll talk about, that adds immunotherapy to bevacizumab. We’ll talk about what that means in the setting of combination therapy. Tom Herzog, what percentage of patients do you think receive frontline bevacizumab in the United States today?
Thomas J. Herzog, MD: As best I can tell, it’s about 40% right now.
Bradley J. Monk, MD: Katie and Sharyn, what do you think?
Kathleen N. Moore, MD: I would think it’s a little higher, but 40% may be correct. The market data that I’ve heard have it around 50%, maybe a little higher. But that’s a ballpark estimate.
Bradley J. Monk, MD: Sharyn, what do you think?
Sharyn N. Lewin, MD: Agreed. The market data that I’ve heard as well are between 40% and 50%.
Bradley J. Monk, MD: One of the things that’s interesting is that the medical oncologists use it a little more. The medical oncologists were earlier adapters because of the use in colorectal cancer and lung cancer. I really don’t have any evidence of that, but certainly that has been my observation.
Transcript Edited for Clarity