Neoadjuvant Chemo VS Cytoreductive Surgery in OC



Bradley J. Monk, MD, FACS, FACOG: Hello and thank you for joining us today. We continue to work diligently toward improving outcomes for women with advanced ovarian, fallopian tube, and peritoneal malignancies, with the hope of earlier diagnosis and longer recurrence-free survival, improved patient reported outcomes, what we call survivorship, and ultimately, improving overall survival. In this OncLive Peer Exchange® discussion on advanced ovarian cancer entitled, “Optimizing Therapy Based on Current Data,” my colleagues and I will provide a clinically relevant perspective on the most recent trial data, including information from the European Society of Medical Oncology 2018 annual meeting in Munich, Germany.

My name is Brad Monk. I’m a professor of gynecologic oncology at the University of Arizona College of Medicine in Phoenix, Arizona, and Creighton University School of Medicine at St. Joseph’s Hospital and Medical Center in Phoenix. I’m also the medical director of the US Oncology Research Program, and also part of Arizona Oncology.

Participating today are my 2 distinguished panelists. Dr Michael Birrer, professor of medicine in hematology and oncology, the Evalina B. Spencer Chair in Oncology, and director of the University of Alabama Comprehensive Cancer Center. Welcome, Mike.

And also Dr Ursula Matulonis, chief of the division of gynecologic oncology for the Susan F. Smith Center for Women’s Cancers, and institute physician and professor of medicine at Harvard Medical School in Boston, Massachusetts. Ursula, thank you.

Ursula A. Matulonis, MD: It’s great to be here, thank you.

Bradley J. Monk, MD, FACS, FACOG: It’s exciting. It’s been such a great ride since 2014 when targeted therapy really was launched in ovarian cancer. So, we’re going to talk today about ovarian cancer, epithelial cancers, fallopian tube, and peritoneal. And Michael, why don’t you start off. So, all of these patients need an operation. Tell us about it—and I get it you’re not a surgeon, but I’m kind of a medical oncologist and you’re kind of a surgeon. So, tell us about the staging and when the debulking happens in an ovarian cancer patient.

Michael J. Birrer, MD, PhD: Well, as a medical oncologist I could do the surgery, but it’s not going to come out well. But even this area in ovarian cancer has changed. Now, from a number of randomized phase III trials we know that neoadjuvant therapy is essentially equivalent to primary debulking. And that was a very large step forward. And certainly, our European colleagues adopted that I think initially, faster than us. And in the states now the pickup has been fairly rapid. [An estimated] 40% to 60% of patients are now getting neoadjuvant therapy, meaning they get their chemotherapy first and then after 3 cycles they get interval debulking.

And I think part of what’s driving that is that the surgery is a little bit easier. At least my colleagues tell me that after 3 cycles, resecting the tumor [that is] left is easier. From a scientific standpoint, frankly we love it because we get tissue at the beginning of the diagnosis and we get tissue afterwards and we have matched pairs. That creates a lot of interesting science. So, it’s shifting, and it also raises up an interesting clinical issue, which is, who do you triage for primary debulking versus interval debulking?

Bradley J. Monk, MD, FACS, FACOG: I always say that’s one of the hardest decisions we make—primary versus interval debulking. Clearly in a neoadjuvant [setting], chemotherapy is the right treatment for patients who cannot have complete resection where there’s cancer everywhere. And if you don’t know who that is based on a CAT [computed axial tomography] scan, physical examination and so on, you stick the laparoscope in and try to figure it out.

Ursula, in Boston, what percentage of patients start with chemotherapy, or start with surgery?

Ursula A. Matulonis, MD: I think it’s probably between 40% [and] 50% will have upfront surgery, so it sort of bridges that 50/50 range.

Bradley J. Monk, MD, FACS, FACOG: It’s common, it’s common. And our preference is primary debulking if you can do it.

Ursula A. Matulonis, MD: Correct, that’s right.

Bradley J. Monk, MD, FACS, FACOG: And so, the American Society of Clinical Oncology recommends that every patient be evaluated by a surgeon.

Ursula A. Matulonis, MD: Correct.

Bradley J. Monk, MD, FACS, FACOG: And then once that decision is made we can work together as a team, and medical oncologists—I’ve 2 here, 1 on my right, 1 on my left—can take good care of ovarian cancer patients. So that’s an exciting time.

Ursula A. Matulonis, MD: I just want to make one comment about neoadjuvant chemotherapy, something that I see come up not too infrequently, is making that initial diagnosis. So, you say, put the laparoscope in; sure you’re going to get tissue, a nice hunk of a disease or a node, but in the community sometimes I still see diagnoses made by simple removal of ascites through paracentesis. And there have been some good guidelines published now around the appropriate use of neoadjuvant chemotherapy where you really do need to make a tissue diagnosis based upon a biopsy.

Bradley J. Monk, MD, FACS, FACOG: A core biopsy.

Ursula A. Matulonis, MD: A core biopsy, that’s right. Because that cytology may come up just simply adenocarcinoma. It could be borderline tumor, it could be something else, another primary tumor.

Transcript Edited for Clarity

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