PARP Inhibition in Recurrent Ovarian Cancer

Thomas Krivak, MD:As we start to move more to biologic agents, there’s no doubt about it that at this past ASCO [American Society of Clinical Oncology Annual Meeting], the AVANOVA data were utilized in patients instead of using chemotherapy. These patients were randomized to niraparib with bevacizumab versus single-agent niraparib. What we saw in that patient population is that you can substitute biologic therapy instead of chemotherapy.

Combining it with Avastin, you had to bring the patient in, and they had to have some chair time to get their infusion. I think one of the nice things about PARP inhibition is that it’s an oral drug. If you have a patient who has an excellent functional status who doesn’t want to be coming in for chemotherapy infusions—say, their blood counts are fine and they want to get their medications. Then, to know I live in Pittsburgh, say they want to go down to Florida. This way they can fly down to Florida, we can check their labs while they’re in Florida, and then refilling other medications, and fly back once a month, once every other month to have their medications refilled and to make sure their toxicities aren’t there.

I think it releases them from their chair time. A lot of these adverse effects are managed over the phone with our nurse and a PA [physician assistant] to help in taking the medication in the evening. I think helping fatigue with medications are all positive interventions. I think chemotherapy has adverse effects. PARP inhibitors have adverse effects. They’re different profiles. It’s a nice alternative for the patients, and I think it gives them choice. I think when we’re interacting with a patient, the more options and choices we have for those patients—I think that that sounds odd, but that’s comforting, knowing that if this doesn’t work, we have these choices. The patient doesn’t feel pain and say, “This is my only option at this time. I have these other options. I kind of like how this sounds. I can take a pill for a while and not have to worry about chair time,” and so the patients are doing well.

I think this is the conversation that each patient’s going to have. I don’t know, it’s what always I tell the residents, “The science of medicine is understanding the capacity of data, the QUADRA data, the AVANOVA data. The art of medicine is applying that time for each patient, realizing that, you know, I saw 4 patients today, and each of them is receiving treatment for recurrent therapy and each is slightly different. That is just because that’s what the patient said: “Hey, this works better for me and my lifestyle.”

Transcript edited for clarity.

Case: A 58-Year-Old Female With Heavily Pretreated Recurrent Ovarian Cancer

H & P

• 58-year-old female diagnosed in 2014 with stage IV ovarian cancer
  • Pathology: high-grade serous carcinoma, epithelial ovarian cancer
  • CA-125: 460 U/mL
  • CT with contrast of the pelvis, abdomen, and chest revealed a 4-cm mass in the left ovary and peritoneal carcinomatosis
  • Patient underwent suboptimal debulking surgery; residual disease 1.5 cm
  • Received IV/IP carboplatin/paclitaxel (6 cycles); achieved complete remission
• 2 years later (2016) symptoms returned; CA 125, 255 U/mL; ECOG: 1
  • Received carboplatin/paclitaxel (6 cycles) and bevacizumab; achieved good partial remission; CA 125, 45 U/mL; continued on bevacizumab maintenance
• 1.5-years following second-line therapy (2017), again presented with symptoms; CA 125, 550 U/mL; ECOG: 0
  • Genetic testing;gBRCA1/2wild-type
  • Received carboplatin/gemcitabine (6 cycles); CA 125, 46 U/mL; achieved complete remission
• Currently:
  • CA 125, 620 U/mL
  • CT shows several small masses in the lung left lower lobe (largest is 3 cm)
  • ECOG: 0