To Treat Ovarian Cancer With PARP Inhibitors or Not: Factoring the Progression-Free Survival Benefit and Side Effects Into the Decision

Do the Benefits From these Drugs Make Up for the Risks?

• ASCO guidelines recommend niraparib for first-line maintenance in patients with stage III or IV epithelial ovarian cancer, with or without BRCA mutations
• PARP inhibitors are also recommended in recurrent, platinum-sensitive disease
• Gynecologic oncologists say they offer every patient these drugs, but with careful consideration about benefits vs. toxicity

For all of us in gynecologic oncology, PARP inhibitors have become an increasingly important tool we can offer our patients. The question now is, which patients should receive them, and when.

“Doctors are excited about having an option for maintenance therapy in ovarian cancer patients, not only in recurrent platinum-sensitive disease, but also in first-line maintenance,” Stanford Medicine gynecologic oncologist, Dr. Oliver Dorigo, tells a SurvivorNet Connect panel during a virtual conference on ovarian cancer in the age of COVID-19.

The NOVA trial established that niraparib as maintenance therapy in platinum-sensitive patients significantly improved progression-free survival compared to placebo, regardless of women’s BRCA or homologous recombination deficiency (HRD) status. Then, the PRIMA study found the treatment extended PFS in patients with newly diagnosed ovarian cancer, with or without HRD deficiency.

“There’s a substantial benefit to patients who have a deficiency in homologous recombination, and those I would imagine are going to be pretty much no-brainers,” adds NYU Langone gynecologic oncologist, Dr. Douglas A. Levine. The answer isn’t as clear for HR-proficient patients, however, who may only get three months of PFS on treatment, and may have to deal with significant side effects like lower platelet counts and anemia in return.

In recent months, COVID-19 has factored into the decision-making process. Dr. Dorigo had two patients choose a PARP inhibitor over bevacizumab, simply because they didn’t want to come in for an infusion.

Ultimately, the choice of whether to go on a PARP inhibitor comes down to a patient’s goals, says Dr. Bobbie J. Rimel, obstetrician/gynecologist and oncologist at Cedars-Sinai. While some patients may want to return to their job for the health benefits it provides, treatment may make them too fatigued to work. “That’s a conversation we have a lot in my practice, about whether or not we think the magnitude of benefit that a patient’s going to experience is going to make up for the things they might lose.”