Robert W. Holloway, MD, and Chad A. Hamilton, MD, provide clinical pearls for community physicians using maintenance therapies for ovarian cancer.
Chad A. Hamilton, MD: Do you have any clinical pearls or tips in your experience for providers who perhaps haven’t used maintenance therapy or are thinking about incorporating maintenance therapy into their practice?
Robert W. Holloway, MD: I do have several, but it’s an interesting observation that, I still think the majority of patients with ovarian cancer in the United States may not be offered maintenance therapy. Maybe we’re passing over the 50/50 mark, but when we speak to our colleagues, like you and I, who have been using these maintenance therapies, we are kind of in a silo and think that all patients with ovarian cancer are offered these drugs. But as you know from referrals that you get, out in the community, a lot of patients don’t get offered maintenance therapy. It’s probably from days of old where our maintenance therapies were pretty limited and were cytotoxic, and there was a clear question about quality of life and benefit with cytotoxic agents, and wearing the bone marrow out. I think some of the hesitancy is that question about quality of life. There is more than one clinical trial that has looked at that and shown, despite what our bias would be, that if you’ve got adverse effects such as nausea, fatigue, and anemia, that the quality of life indexes are not measurably different. That’s because the control groups in these studies are having symptoms from their disease, so quality life for the population does not diminish on maintenance therapy.
The way I discuss it with my patients is that we have ways we can control fatigue, nausea, and loss of taste. Many of these adverse effects, as you know, tend to go away after a couple of months, but what we can control is progression of disease, pain, and bowel obstruction. By keeping patients off cytotoxic therapy, we’re hopefully preserving their bone marrow reserve. I tell them that their progression-free time, their maintenance time, is really time for them to travel, to get their life back, to exercise, and to get their physical endurance back, because we’re kind of trying to keep them in good shape to fight another battle another day for many of these patients. So, I really encourage them, if they’re coming out of chemotherapy weak, to get back into physical therapy. I tell them it’s time to join the YMCA again, start exercising, and enjoying life again. I can usually maintain patients and get them through their adverse effect profile.
For some of the basic tips as you had asked about, I do premedicate my patients the first week or two. Nausea is one of the common adverse effects for most PARP inhibitors, and I think if you’re going to start a patient on a new drug and they have a horrible experience the first week with vomiting, it’s hard to keep them on the horse, so to speak. They’ll tell you they just can’t take the drug. I will use prophylaxis with antiemetics for the first 1 to 2 weeks and then tell them to use it as needed. I put all patients on antacids, and I tell them to take it with food. For niraparib in particular, I tell them to take it after their evening meal, so that if they do get nausea, hopefully they’re sleeping through it for at least a significant amount of that time. And for the fatigue issue, which is also very common, I really encourage everyone to start aerobic exercise. For most of our older patients, that just means getting out and walking 20 minutes once or twice a day, and trying to establish that habit and getting their muscles back in shape so that they’re not feeling so fatigued.
Chad A. Hamilton, MD: I may steal some of your advice to patients. Those are great thoughts to help patients understand why they’re on the medication and to tolerate it better. On the flip side, when I think of it, I have a lot of community physicians who are geographically remote from where I am, so I’ve had the experience of seeing firsthand some of our challenges with getting the information out there about these changes and advances in ovarian cancer. We have great community oncologists who are treating multiple different disease sites. It’s really been a challenge the past couple of years to get out and talk to people about what’s happening in ovarian cancer. Some folks may see just a handful of patients a year, whereas like you mentioned, we’re in a silo, immersed in these changes. It’s really been a struggle to get that out to communities, particularly in places that are somewhat geographically remote from the cancer centers. It’s been a conversation for me with those providers who refer in to me.
The first step is making sure that the genetic testing is done, both germline and somatic. Then we have a conversation about why the somatic testing may be important, and then really encouraging folks to jump in. I usually treat my own patients with the surgery and chemotherapy, but I do partner with a lot of people out there who treat with chemotherapy when my patients live a good distance away. Like with every newer drug, I say to jump in, and we learn very quickly how to manage the adverse effects of it. We learn very quickly how to help patients get through it. In a lot of ways, the medical oncologists who are out there may be more familiar with some of these drugs, just not as familiar with them in ovarian cancer. I think the folks I’ve talked to have been very receptive to it, but there has been a gap in getting the information out there about it, and sharing the excitement we’ve had as a specialty about the advances that we’ve seen in maintenance therapy over the past few years. I think it’s a matter of time, and I see it gradually increasing. I think we just have to continue to make that push to get the information out there both to patients and providers, and help both groups learn how to manage the medications and adverse effects better.
Transcript edited for clarity.