Changing Strategies for Treating Ovarian Cancer

In randomized controlled trials conducted in the U.S. — and all over the world — this approach has proven beneficial.  And in the era of COVID-19, doctors have found it may be safer to delay surgery for a few weeks, as patients undergo the first cycles of chemotherapy.

While doctors will continue to determine the best treatment approach on a case-by-case basis, studies have shown that delivering several doses of chemotherapy in advance of surgery can be beneficial for several reasons:

• Better surgical outcomes
• Fewer post-surgery complications
• Time for patients to prepare themselves for surgery

Neoadjuvant chemotherapy may be paired with bevacizumab (brand name Avastin) a drug that is used for ovarian cancer. The drug is administered intravenously and can be given in combination with other chemotherapy drugs.  Avastin works by affecting the growth of blood vessels, starving tumors of the blood they need as nourishment. Avastin may also be used as a maintenance therapy for a year or so after surgery and was just approved by the FDA to be used in conjunction with the PARP inhibitor olaparib (brand name LYNPARZA) in HRD (Homologous Recombination Deficiency) positive women who show a response to platinum-based chemotherapy.  The results of a recent trial showed an increase in progression-free survival from an average of 17 to 37 months in women with HRD and a BRCA mutation using this regimen. For women with HRD but no BRCA mutation the improvement was 16.6 to 28 months.

The FDA has also approved another PARP inhibitor niraparib (brand name ZEJULA) for almost all women regardless of whether they have the BRCA mutation, as part of an initial course of treatment, or what's called front-line treatment.

Most recently, the American Society of Clinical Oncology (ASCO) released new guidelines recommending PARP inhibitors be offered to women, with or without genetic mutations, who are newly diagnosed with stage III or IV ovarian cancer and have improved with chemotherapy.

The Goal: Optimal Surgery

“One of the strongest predictors of ovarian cancer survival is an optimal surgery,” says Dr. Chapman. “This means that, at the time of surgery, all of the visible disease is removed.”  Unfortunately, in cases where the cancer has wrapped itself around crucial blood vessels near the liver — or spread into the lungs, she notes, “sometimes, that’s just not possible. There are places where we just simply cannot optimally reduce the volume of the cancer if we start with surgery.”

In these cases, the new strategy – with chemo given ahead of surgery — can make the difference.

“Chemotherapy is really beneficial for those patients,” Dr. Chapman explains, “because it will decrease the volume of cancer and make their surgery more likely to be optimal.”

Doctors also consider the patient’s overall health. “I talk to patients about whether or not their bodies are physically capable of tolerating such a surgery,” she explains. In some cases, the time spent during neoadjuvant chemotherapy gives patients time to get themselves stronger and prepare for surgery.

Another positive finding from this research: When chemotherapy precedes surgery, complication rates go down.

An Individual Decision

Oncologists always keep in mind that an individual patient may not fit a particular study or statistic. “There might be some patients for whom surgery is better as a first strategy, ” Dr. Chapman acknowledges.

“And we certainly know that there are some patients for whom neoadjuvant chemo, starting with chemo, is the better strategy.” For this reason, the best strategy to approach ovarian cancer treatment is always an individual decision between a patient and her oncologist.

 

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