when cancer comes back, sarah adams, md

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Recurrent Ovarian Cancer

Recurrent Ovarian CancerOvarian Cancer Research Fund Alliance 2016 Conference Sarah Adams, MD

DisclosuresClinical trial support from Astra Zeneca

Research supportOvarian Cancer Research FundAmerican Cancer SocietyAmerican Society of Clinical OncologyOxnard FoundationPhi Beta Psi FoundationOvarian Cancer SPOREUniversity of Pennsylvania Research FoundationNational Institutes of Health Sandy Rollman FoundationKaleidoscope of Hope FoundationGynecologic Cancer Foundation

OutlineWhat are the chances that ovarian cancer will return after initial treatment?What symptoms might suggest recurrent disease?How is a recurrence diagnosed or confirmed?What treatment options are available and what factors affect decisions about which to choose?Are there benefits to enrolling in a clinical trial?

Ovarian cancer subtypes

Most ovarian cancers arise from the lining of the ovary the epithelial layer

Cancers arising from germ cells (eggs) or stromal cells are less common

In this presentation, I will focus on epithelial cancers (ovarian, tubal, peritoneal)

Ovarian cancer subtypes

Accumulating data indicates that serous ovarian cancers may actually develop in the fallopian tubes and then spread to the ovary.

Initial treatment: curative intentPrimary treatment:Debulking or cytoreductive surgeryChemotherapyNeo-adjuvant chemotherapy (chemotherapy before surgery)Primary adjuvant chemotherapy (chemotherapy after surgery)

Initial treatment: curative intentPrimary treatment:Debulking or cytoreductive surgeryChemotherapyNeo-adjuvant chemotherapy (chemotherapy before surgery)Primary adjuvant chemotherapy (chemotherapy after surgery)[Maintenance therapy: ongoing chemotherapy to reduce the risk of recurrence]

Initial treatment: curative intentPrimary treatment:Debulking or cytoreductive surgeryChemotherapyNeo-adjuvant chemotherapy (chemotherapy before surgery)Primary adjuvant chemotherapy (chemotherapy after surgery)[Maintenance therapy: ongoing chemotherapy to reduce the risk of recurrence]

Cancer surveillance:3-month intervals for two years4-month intervals for the third year6-month intervals for up to 10 years

What are the chances that ovarian cancer will return after initial treatment?

0% 10% 20% 30% 40% 50% 60%70%80%90%Approximate Percentage of RecurrenceStage I

Stage II

Stage III (optimal)

Stage III (suboptimal)

Stage IVOvarian cancer recurrence

What symptoms might suggest recurrent disease?

Symptoms associated with ovarian cancer recurrenceBloating, abdominal fullness, increased girth, indigestionPelvic painChange in bowel or bladder habitsEarly satietyVaginal discharge or bleedingPain with intercourseLymphedema / leg swellingShortness of breathNausea, vomiting

*Any new or persistent symptoms should be reported to your oncologist

How is a recurrence diagnosed or confirmed?

Physical examPhysical examEvaluation of lymph nodes Chest exam for pleural fluidAbdominal exam for masses, fullness, fluid accumulation, painPelvic exam for masses or nodularityExtremities for swelling, tenderness, range of motion

35% who presented with symptoms had a normal physical exam

CA12561% of women are diagnosed with recurrence based on an elevated CA125 level

Rises in CA125 may precede symptomatic relapse by a median of 4.5 months (range 0.5-29.5 months)

Doubling of CA125 has a sensitivity of 86% and a specificity of 91% for detecting progression.

A second confirmatory value reduces the false-negative rate to 24 mos)Absence of ascitesGood performance status

As with primary surgery, the best outcomes are seen in patients who can be optimally debulked

Minimally invasive options (robotic or laparoscopic surgery) may reduce morbidity for eligible women

ChemotherapyMost patients respond to second-line chemotherapy

Response to second-line chemotherapy predicted by:

Tumor type, size, and number of disease sites

Duration of response to previous platinum-based regimen, platinum-free interval and TFI (most important)TFI 12 mos: Response Rate 52-62%

Platinum sensitivity Most women with ovarian cancer receive a platinum drug (carboplatin, cisplatin, oxaloplatin) as part of their primary chemotherapy regimen. The time to recurrence after platinum treatment determines platinum sensitivity

Response to platinumLikely secondary treatmentExamplesPlatinum sensitive >6 months without recurrenceAnother platinum-based regimen Carboplatin alone or in combination with another drugPlatinum resistant < 6 months until recurrenceA non-platinum drugDoxil, Taxol, Gemzar, TopotecanPlatinum refractory Failure to achieve remission A non-platinum drugDoxil, Taxol, Gemzar, Topotecan

Platinum sensitivity Most women with ovarian cancer receive a platinum drug (carboplatin, cisplatin, oxaloplatin) as part of their primary chemotherapy regimen. The time to recurrence after platinum treatment determines platinum sensitivity

Response to platinumLikely secondary treatmentExamplesPlatinum sensitive >6 months without recurrenceAnother platinum-based regimen Carboplatin, often in combination with another drugPlatinum resistant < 6 months until recurrenceA non-platinum drugDoxil, Taxol, Gemzar, TopotecanPlatinum refractory Failure to achieve remission A non-platinum drugDoxil, Taxol, Gemzar, Topotecan

Platinum sensitivity Most women with ovarian cancer receive a platinum drug (carboplatin, cisplatin, oxaloplatin) as part of their primary chemotherapy regimen. The time to recurrence after platinum treatment determines platinum sensitivity

Response to platinumLikely secondary treatmentExamplesPlatinum sensitive >6 months without recurrenceAnother platinum-based regimen Carboplatin alone or in combination with another drugPlatinum resistant < 6 months until recurrenceA non-platinum drugDoxil, Taxol, Gemzar, TopotecanPlatinum refractory Failure to achieve remission A non-platinum drugDoxil, Taxol, Gemzar, Topotecan

Platinum sensitivity Most women with ovarian cancer receive a platinum drug (carboplatin, cisplatin, oxaloplatin) as part of their primary chemotherapy regimen. The time to recurrence after platinum treatment determines platinum sensitivity

Response to platinumLikely secondary treatmentExamplesPlatinum sensitive >6 months without recurrenceAnother platinum-based regimen Carboplatin alone or in combination with another drugPlatinum resistant < 6 months until recurrenceA non-platinum drugDoxil, Taxol, Gemzar, TopotecanPlatinum refractory Failure to achieve remission A non-platinum drugDoxil, Taxol, Gemzar, Topotecan

Study(number of patients)AgentsResponse Rate (%)Median progression free survival (months)Median overall survival (months)ICON 4 (802)Carboplatin Carboplatin + Taxol54% 66%912*2429*AGO (366)Carboplatin Carboplatin + Gemcitabine31%47%5.88.6*17.318CALYPSO (976)Carboplatin + TaxolCarboplatin + Doxil9.411.3*31.5

OCEANS (484)Carboplatin + GemcitabineCarbo+Gem+Avastin57%79%8.412.4*35.233.3

Clinical trials in platinum-sensitive patients with recurrent ovarian cancerColeman R, et al. Nat Rev Clin Oncol 5 Feb 2013

Response rates to second-line treatment are high among women with platinum sensitive disease.

Study(number of patients)AgentsResponse Rate (%)Median progression free survival (months)Median overall survival (months)ICON 4 (802)Carboplatin Carboplatin + Taxol54% 66%912*2429*AGO (366)Carboplatin Carboplatin + Gemcitabine31%47%5.88.6*17.318CALYPSO (976)Carboplatin + TaxolCarboplatin + Doxil9.411.3*31.5

OCEANS (484)Carboplatin + GemcitabineCarbo+Gem+Avastin57%79%8.412.4*35.233.3

Clinical trials in platinum-sensitive patients with recurrent ovarian cancerColeman R, et al. Nat Rev Clin Oncol 5 Feb 2013

Platinum-sensitive patients are usually treated with another platinum-containing regimen often carboplatin in combination with a second drug.

AgentResponse Rate (%)Median progression free survival (months)Median overall survival (months)Side effectsDoxil10-20%3-410-12Hand-foot syndrome, mucositisTopotecan12-18%3-410-12MyelosuppressionTaxotere22%3.512.7MyelosuppressionGemzar15%4-511.8-12.7MyelosuppressionEtoposide6-27%4-510-11MyelosuppressionTaxol10-30%4-613Myelosuppression, neuropthyAvastin21%4.717Hypertension, blood clots

Most-frequently used agents in platinum-resistant diseaseColeman R, et al. Nat Rev Clin Oncol 5 Feb 2013

Because of the more limited prognosis associated with platinum-resistant disease, reducing toxicity becomes a primary goal, and typically single agent protocols are used.

Targeted agentsAdvantages:Different (often more limited) toxicity profileMay be active in chemotherapy resistant diseaseBetter understood mechanism of action

Bevacizumab (Avastin): blocks blood vessel formation in tumorsAlso has immune modulatory effectsresponse rate greater than 20% (6 mo PFS 28-40%)

PARP-inhibitors: block single-stranded DNA repairbest response is among women with BRCA gene mutationsresponse rates as high as 33% in recurrent EOC

Hormone therapyAdvantages:Lower toxicityOral administration

Tamoxifen: Response rate of 17-20% among women with recurrent ovarian cancer

Fulvestrant (selective estrogen receptor modulator)Maintained disease stability in 50-64% of patients, 30% at 90 days

Aromatase InhibitorsModest objective RR of 8-15%, stability in 19-24%Evidence for efficacy in low grade serous cancers

RadiotherapyWhole abdominal radiation therapy is associated with significant toxicity and has limited efficacy in the treatment of recurrent disease

Localized radiation may be effectiveGood for symptom con

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