Shifting Paradigms in Ovarian Cancer - Episode 3
Bradley J. Monk, MD, FACOG, FACS: Let’s transition to secondary debulking. Brian, tell us a little bit about the passion of the Germans and the DESKTOP sort of idea. What are they thinking, and what is the idea of a secondary operation?
Brian M. Slomovitz, MD: That’s a great question, Brad. When we’re talking about the secondary cytoreduction, we’re talking about those patients with platinum-sensitive recurrent disease. So that means that the disease came back 6 months or greater from the time that they finished their first-line chemotherapy. The rationale really is: Who are good candidates, or is everyone a good candidate for this type of surgery? I think we refer to the German study, and there was a study that was done here in the US as well. We need to really identify a group of patients who may benefit from secondary cytoreduction and then better study that group of patients. The results of the study so far show that in all-comers, it’s probably not going to portend a better prognosis. But in my practice, for example, I have a patient who’s 8 years out from her primary surgery and chemotherapy, a very unusual case, with an isolated recurrence, which is biopsy-proved ovarian cancer. I’m going to take it out.
Bradley J. Monk, MD, FACOG, FACS: Yeah. That’s what the Germans would suggest. If you had an R0 in the beginning, if you lack ascites, and you have oligometastases, that you have a success of about three-quarters to have a complete resection, which is the goal. GOG-0213 didn’t show that.
Kathleen N. Moore, MD: Correct.
Bradley J. Monk, MD, FACOG, FACS: And so tell us what GOG-0213 is and if that has affected your practice?
Kathleen N. Moore, MD: GOG-0213 is similar but distinct from DESKTOP OVAR, which is the German study. It’s similar in that it took patients who were considered eligible for platinum and for whom the treating physician felt like surgery was reasonable. That was sort of the criteria. There were 2 randomizations: 1 for chemotherapy with or without bevacizumab, but the 1 we’re talking about is randomizing them to secondary surgery, or just straight on to chemotherapy. That’s different from the DESKTOP OVAR, which had very specific criteria, as you just mentioned—performance status, no ascites, complete resection at primary surgery. So different populations.
Bradley J. Monk, MD, FACOG, FACS: But the R0 rates were the same in both studies. So they got to the same place.
Kathleen N. Moore, MD: They got to the same place. It was a little bit lower in GOG-0213 but was really statistically similar. When you look, GOG-0213 has been able to show not only progression-free survival but overall survival. DESKTOP OVAR has presented only progression-free survival. They both showed the same thing. In patients for whom you got to no gross residual disease, the progression-free survival was greater. If you left anything or didn’t do surgery, they did about the same. And so there’s no point in going if you don’t get it all out. The curves almost overlie one another between the 2 studies. That makes sense, because if you take the tumor out, your progression-free survival better be longer or something is really wrong. And so, that’s where DESKTOP OVAR starts, and we await the overall survival data. GOG-0213 has overall survival, and quite surprisingly, the overall survival was poorer.
Bradley J. Monk, MD, FACOG, FACS: A year less.
Kathleen N. Moore, MD: A year less.
Bradley J. Monk, MD, FACOG, FACS: So if you do a second operation, you shorten your patient’s life by a year.
Kathleen N. Moore, MD: A year. I can’t explain it.
Bradley J. Monk, MD, FACOG, FACS: I think that’s surprising, quite frankly, because R0 patients do better. You said it. But they don’t do better because you have a bigger knife; they do better because, as Elena said, they have better biology.
Elena S. Ratner, MD: Biology of disease.
Bradley J. Monk, MD, FACOG, FACS: Has that changed your thoughts? I always said it takes 2 studies to convince anyone of anything. GOG-0213 is only 1 study, so I’ll give you a pass if you’re waiting for the DESKTOP III data. But what do you think?
Elena S. Ratner, MD: It hurts me, as a surgeon.
Bradley J. Monk, MD, FACOG, FACS: Why?
Elena S. Ratner, MD: I don’t know what to do.
Bradley J. Monk, MD, FACOG, FACS: It hurts your patients when you do it.
Elena S. Ratner, MD: Valid point. But yes, the data of course speaks. I think once we see the overall survival of the DESKTOP trial it will be clearer. But again, I think everything is personalized. Regarding Brian’s patient, I would do the same. Isolate the tumor. I believe in stem cells. I believe that there are some sort of clones in a subset of tumors that cannot be destroyed with chemotherapy and that need to be surgically destroyed.
Bradley J. Monk, MD, FACOG, FACS: The other thing that has changed the frequency of secondary debulking is how we closely monitor patients.
Brian M. Slomovitz, MD: Right.
Bradley J. Monk, MD, FACOG, FACS: So even though there was a suggestion that maybe CA 125 [cancer antigen 125] monitoring was not recommended, we still all do it. And then when the CA 125 level goes up, we find very, very small-volume disease, if any. So we don’t just watch the patient until they have something that might need to be cut out. That’s the other reason why secondary debulking is almost never practiced.
Brian M. Slomovitz, MD: And in the first-line setting, I know it was talked about earlier, maybe a minimally invasive approach after neoadjuvant.… I’m not in favor of that. In the first-line setting, I believe a person needs a vertical midline incision to make sure there’s no palpable disease. However, in the platinum-sensitive setting, if there’s an isolated recurrence, we can take advantage of the surgical technology we have now, using either robotic or minimally invasive.
Bradley J. Monk, MD, FACOG, FACS: Or the radiation oncology technology and d
Transcript Edited for Clarity