Reacting to a Diagnosis of Recurrent Ovarian Cancer
Dr. Ramez N. Eskander and Dr. Jeremy Hirst consider the implications of a diagnosis of recurrent ovarian cancer.
PUBLISHED October 18, 2019
Shubham Pant, M.D.: Let me go on to a different aspect. Dr. Eskander, I’m going to talk to you about it. With Doña, we talked before and she’s doing wonderful. She’s out of her diagnosis. She’s doing great. But some patients have recurrent disease. That means the disease does come back. What are the unique challenges in the diagnosis and treatment of recurrent disease? That means disease that comes back for patients with ovarian cancer.
Ramez N. Eskander, M.D.: It’s tough. It’s tough for many reasons, because patients now have access to go read what recurrent ovarian cancer means, and they read about it on the Internet. And many times, what they read is that once it comes back, you can’t get it to go away permanently again. It is a difficult conversation for some patients. Again, I think the key and the priority has to be education, and creating a realistic set of expectations for the patient, and having open communication.
When patients are diagnosed with recurrent ovarian cancer, I like to tell them, “Listen, this is another starting point for us. This doesn’t mean that we don’t have options. It doesn’t mean that there isn’t anything that we can do to help put you back into remission and manage this disease.” We’re going to start with the information that we have, and thankfully, as Doña alluded to earlier, we are in a time where the amount of information that we have at our fingertips, the opportunities we have for treatment for molecular profiling of tumors, and the understanding of what targets may exist, is well beyond what existed five, seven years ago. There are a myriad of opportunities that are available for us to treat patients and offer them therapeutic interventions that will hopefully put their cancer back into remission. Again, I like to tell them we’ll take it one step at a time. This is recurrence No. 1.
Shubham Pant, M.D.: No. 1, yes.
Ramez N. Eskander, M.D.: Let’s deal with this recurrence. Let’s see where this path takes us, and then we will decide what we need to do next if anything. But the hope is to get the patient back into remission and hopefully a durable and long remission at that.
Shubham Pant, M.D.: Normally, I tell my patients that we’ll cross the bridge when we come to it. Right now, we are here, and then for the next step we will do that. But normally is it chemotherapy or targeted therapy? Is it lifelong, or do you give it for some time and then stop? I know every patient is different, but what are the general outlines of therapy?
Ramez N. Eskander, M.D.: In general, with recurrent disease, there are again a few opportunities. No. 1 is — and I bring this up because I’m a big advocate of understanding the ways we can treat our patients better — if there is a clinical trial that a patient may be eligible for and is interested in, that’s an opportunity. In terms of current standards of care, it’s combination-based platinum chemotherapy for a platinum-sensitive recurrence. That decision is made by determining how long the cancer stayed away after completion of frontline chemotherapy. If they have a platinum-sensitive recurrence, it’s a platinum-based combination regimen. Again, you can use Avastin, or bevacizumab, in conjunction with that and as a maintenance.
More recently, with our understanding of the BRCA implications in all patients, there’s an opportunity in platinum-sensitive patients to go on PARP inhibitor maintenance therapy. And that maintenance is essentially duration of disease remission, response, or unacceptable toxicity. If the patient has a really, really amazing response, and they’re on it for a long period of time, we potentially may visit a conversation about what to do at that point. But we do have maintenance therapy options that didn’t exist previously for these patients. The platinum-resistant patient population is a different conversation altogether, but again it highlights the importance of tailoring the treatment to where a patient is in their disease.
Shubham Pant, M.D.: The right patients. When patients hear about this, let’s say the second time around, what are their reactions? Is it similar to the first time around? Is it different, now that they’ve been through once and they understand what they’re going through, if they have to get chemotherapy again? What kind of reactions do you see with patients?
Ramez N. Eskander, M.D.: It’s common for them to be discouraged for the reasons that we just talked about. But I try to reassure them and say again that we have effective options for treatment. And they are familiar with chemotherapy, they’re familiar with infusions and infusion visits and symptom management. That familiarity makes it, to a certain degree, easier on them. But it can still be difficult to navigate the disease-recurrence setting and help them cope with knowing that it’s back and talking about management going forward.