Robert Coleman, MD, FACOG, FACS
Although the prevalence of ovarian cancer has increased in the last 3 years, incidence and death rates have decreased as a result of novel therapies, including angiogenesis inhibitors, immunotherapies, PARP inhibitors, and refined patient classification schemes, explained Robert L. Coleman, MD, FACOG, FACS.
“We’re excited about where this field is going now that we have some active compounds,” said Coleman, a professor in the Department of Gynecologic Oncology and Reproductive Medicine at The University of Texas MD Anderson Cancer Center.
In an interview during the 2018 OncLive®
State of the Science Summit™ on Ovarian Cancer, Coleman discussed the evolution of treatment for patients with ovarian cancer, the therapies with the most potential, and the importance of classification schemes in directing treatment in recurrent disease.
OncLive: How has the field of recurrent ovarian cancer evolved in recent years?
: One of the things that I’ve mentioned many times, but [that] is becoming more apparent, is that the prevalence of ovarian cancer is increasing. A lot of that is due to the fact that women who have recurred are being treated multiple times with therapies that are extending the time of progression independently. Very few trials we have now can show an overall survival (OS) change in patients who enter the trial at one point as a cohort. We do see a lot of progression-free survival (PFS) advancements. On an individual level, when that is what a patient experiences, the life expectancy of that patient increases.
I pulled the Surveillance, Epidemiology, and End Results data to see what the prevalence of ovarian cancer is doing. Incidence and death rates are declining, but they’re declining at the same rate, by approximately 1% per year. The prevalence, or the number of women who have the disease at any one time, has increased by almost 20% in the last 3 years. That’s really remarkable. [The decline] is a tribute to a lot of the standards of care that we’ve now developed through multiple clinical trials.
I walked through the treatment regimens for the individual classification schemes. Traditionally, we’ve looked at the time the patient is finished with frontline treatment and the time they recur. This is the platinum-free or treatment-free interval. That number seems to be increasing slightly because we’re getting a little bit better at surgery and we’re doing a little bit better job with our frontline therapies. Now, bevacizumab (Avastin) is approved in the frontline setting.
These patients are classified as platinum-sensitive or -resistant. Now, we need to put more details into that. The molecular subtype for BRCA
-positive and -negative patients must be considered as well as their histology and treatment-free interval. These factors have now been incorporated into how we classify patients and what we use for their treatments.
Platinum-resistant patients are generally approached with single agents. We have done some doublet chemotherapy, but the only regimen that seems to have improved the PFS again has been the addition of an anti-VEGF therapy like bevacizumab. The AURELIA trial led to an improvement in PFS and in response, which is important because many of these patients are symptomatic. In 2014, it [became] an additional treatment option for women for which that therapy was considered safe in. Chemotherapy plus bevacizumab is now an approved label.
Most of the therapy for the larger populations of patients that we see, who are initially platinum-sensitive, is dictated by platinum-based doublets. There was a trial that looked at whether or not we should use platinum-based chemotherapy first or following a nonplatinum agent. Results showed that patients did better when they got the most active therapy first; that was the platinum-based chemotherapy. That kind of settled the question of whether or not we should start with something else and see whether we could extend the platinum-free interval. Most of us are convinced that, in many cases, platinum-based chemotherapy with bevacizumab has improved PFS. In GOG-0213, which included paclitaxel and carboplatin, there was an improvement in OS.
The ground rule for patients with platinum-sensitive disease, whether it’s initially platinum-sensitive or considered platinum-sensitive down the road, is to use some kind of platinum doublet in combination with an anti–VEGF-based therapy.