 Michelle, I’m so happy to be here with you today. As an ovarian cancer survivor, I think you have so much to share on your experience. This can help other women. Discuss how you presented with ovarian cancer. What were some of the symptoms or signs that you had? If you could share that with people, I think that could be really important so that they can learn how to identify these important symptoms.

 Absolutely. Thanks for having me here today. I’m glad to be here. I was first diagnosed on October 13, 2014. At the time, I was working for a catering company. I was doing a big event one morning. I don’t know if you’ve ever seen the coffee urns, but they can weigh up to 25 pounds. I was lifting a coffee urn and I injured myself. I ended up going to the emergency room. Twelve hours later, I found out I had a ventral hernia and ovarian cancer. I was completely shocked. I did have signs and symptoms of ovarian cancer. I thought I had IBS [irritable bowel syndrome]. I was told I had IBS. For the better part of 2014, I spent it not feeling quite up to par.

The symptoms that I had matched the symptoms of IBS. I had bloating, diarrhea, feelings of fullness. I just wasn’t really feeling well for a better part of the year.

 So, we’re talking about 10 months where you had these gastrointestinal symptoms?

 At least. It probably was even more than 10 months. It was probably a year and a half, at least.

 I remember you telling me that as well when I first met you. Actually, I don’t think it was the first meeting where you relayed that information. It was maybe the second meeting when you said, “You know, I’ve been feeling badly for a while.” And you did seek care, but you also didn’t push things further because you had so much else going on in your life, family, and work, and trying to put all that first.

 I did. You’re so busy working and living your life. I was working 60 hours a week and was taking care of my mom. She was sick.

 Your story is so common. A lot of women have those same types of symptoms as you did. I would urge anybody out there that has 2 to 3 weeks of persistent daily issues of abdominal bloating, swelling, nausea, vomiting, or a change in their stool habits that just doesn’t seem right.

 And also, feeling that they have to go to the bathroom all the time. So, increased urinary frequency, pelvic pressure, or pelvic pain. If you have those symptoms occurring daily, for 2 to 3 weeks, make that appointment with your doctor. Something else that you said that really resonates with me is that you’re putting everything else first.

 Women do that all the time. You really have to be a strong advocate for yourself and see the right doctor. You went to the emergency department. They referred you to us. I think I saw you pretty quickly?

 It was 2 days later. I was diagnosed on October 13. I saw you on October 17. Then, on the following Tuesday, on the 21, I was having my first of 3 surgeries with you.

 Right. I think sometimes people don’t get into the doctor soon enough. Or, they might go to somebody who doesn’t even know what a gynecologic oncologist is.

 Until I met you, I had no idea. In fact, I went to my family doctor. I had an ultrasound done because I did have these symptoms. So, I went to see him. As I was walking out the door, he said, “You know what? Let’s just double check on this. Let’s get an ultrasound.” So, when I was diagnosed by the emergency room doctor, I literally had my family doctor calling me back just 2 days later saying, “I think you have ovarian cancer.” It all just came on so quickly.

 I think that’s also a really important point to make: how you got the diagnosis. An ultrasound can sometimes lead to the diagnosis, but if you’re having all of these symptoms and your ultrasound is negative, you may have to push for something further, like a CT scan.

I had a patient in whom an ultrasound didn’t show anything. Sometimes, the ovaries can still be very small. People can have something called peritoneal cancer, which acts the same way. The ovaries will be small but they’ll have this small volume cancer all over the peritoneal cavity. The peritoneum is that lining of the abdomen, inside.

So, the other thing is, go see a doctor and make sure you’re getting the right tests. The CA-125 blood test can be helpful. If that’s elevated, and you have something on ultrasound, and you’re of certain age, then the likelihood of you having ovarian cancer is increased. And we’re talking a lot about ovarian cancer but, you know, there’s not just ovarian cancer. There’s tubal cancer that occurs in the fallopian tubes.

 The CA-125 test can actually do that also?

 CA-125 is a good marker for both. It’s a very nonspecific marker. If you have an elevated level of CA-125, it doesn’t necessarily mean ovarian cancer. It could be other things. If you have pneumonia, or any inflammation, or any ‘-itis’—pneumonitis, hepatitis&mdash;those types of things can also cause an elevated level of CA-125. Fibroids can cause an elevated level of CA-125. Congestive heart failure…

 You have to be careful about how you evaluate it. But your story and how you presented with it, and those signs and symptoms, combined with the abnormal ultrasound, definitely would have triggered the next step in evaluation.

Recognizing Ovarian Cancer Signs and Symptoms

 Do you remember when we talked in the clinic about what the next step was in terms of surgery and how we make decisions?

 Our approach is a little different. There’s many different approaches you can have with ovarian cancer. Some people do primary debulking surgery followed by chemotherapy. Others would do neoadjuvant chemotherapy followed by a surgery, in-between, followed by more chemotherapy. It really depends on patient characteristics as well as disease involvement.

 I don’t know if you remember this, but you’re young, you’re healthy, and you thought you had ovarian cancer. So, we talked about doing laparoscopy, first, to determine if we could remove all of the disease.

You were having so many symptoms. You were really uncomfortable.

 I felt like it would be worthwhile to move forward with surgery. So, we did the initial laparoscopy. At the time of the surgery, we did FIGO scoring. You probably don’t remember that, which is OK.

 I don’t. I was so out of it back then.

 That’s OK. We use a certain scoring method. If it’s a certain score, we say, “Hey, we can probably get all of this cancer out. Let’s go ahead and go for it.” Or, if it’s a bigger score, then we know we can’t remove all of the cancer. In this case, we do neoadjuvant chemotherapy.

In your case, I did something a little different. You were having so many symptoms from the mass and the tumor volume that we went ahead. I got that out as best as I could, but I knew I couldn’t get all of your cancer out to be R0.

 And so, we finished, after that, with the thought that we would do IV chemotherapy with bevacizumab, to try to shrink down the cancer as much as possible.

 Then, a few cycles later, we did the bigger surgery with the intent of removing the rest of your cancer. And then, we did the belly wash therapy.

 Yes, the intraperitoneal (IP) chemotherapy. I remember that. They had to roll me.

 What did you think about belly wash therapy compared to the IV chemotherapy, only?

 Well, the IV therapy was much easier, believe it or not. The IP, I was just a little squeamish with a port, I guess.

 Yes. For first-line, standard treatment, I thought that was a really good call on your part.

 That’s how we’re training everybody. We were really aggressive with intraperitoneal therapy. There have been so many studies supporting that approach, demonstrating prolonged survival and disease control. And then, just a year ago, they presented the new results on belly wash therapy, saying that if you combine chemotherapy, and there’s all of these different chemotherapy options with bevacizumab, there was no difference in survival between the groups. But more toxicity. And you lived through this, so you knew that.

 And so, at this time, we have moved away from that belly wash therapy. We’re waiting for some more information. We are waiting for the GOG 252 trial results.

 We’re waiting for that study to get completed so we know more about the survival outcomes. So, with ovarian cancer treatment, there’s no one way, right?

 There’s so many different treatments out there. You just don’t know which one to pick.

 And I’m sure that as a patient that was very confusing?

 It was very confusing because, first of all, I’ve never had cancer before. This was all new to me. They explain all of these different treatments, and I wasn’t sure which one would be best for me. But you made good decisions on that part.

 Thank you. So, after you finished the IP therapy, one of the big things we talked about was, should we keep going with the bevacizumab for maintenance? You were pretty tired at that point.

One of the things I talked about with you, Michelle, I realized I hadn’t even explained this better, was going back to the decision about proceeding with surgery or no surgery. I talked about R0. Many people are honestly thinking, “What on earth is R0?”

 That’s what I was thinking. What is R0?

 I apologize for that. R0 basically denotes that you have no evidence of disease left. We removed it all. It is completely gone. There’s no evidence that we can see, with the naked eye, that there’s any disease left. Then, there are other numbers that you can add in there that denote the volume of residual disease that’s left if it’s not R0. So, that’s the definition of R0.

 So, you’re done with your chemotherapy. You have no evidence of disease. You did do maintenance bevacizumab, but for a short period of time. I think you just got tired and wanted to come off therapy? How hard of a decision was that for you?

 It was hard. At the time, I didn’t know of the other options I had out there. So, if you’re giving up on one treatment, and then opting for another treatment, you need to get your knowledge together. You need to know if that’s the right treatment for you.

 And in that case, we did surveillance. We did watchful waiting. Did you find that period of time, where you were not on treatment, to be more freeing? You were able to do the things you wanted and didn’t have to see me. Or were you more anxious?

 I was more anxious. I felt like I wasn’t being proactive. I was just waiting. So, I feel better when I’m on treatment because I know that I’m being proactive. I’m doing something.

 That’s really interesting. I think it points to the fact that you need to have that discussion. It’s not a one-size-fits all, is it?

It’s really individualized. You may feel a certain way. Somebody else feels a different way.

 Yes. Every treatment is different. Every individual is different.

Ovarian Cancer: Initial Conversations About Surgery 

 Michelle, we went through your initial treatment course really quickly, but I want to back up a little bit and review something that is important for our patients to consider. When we were making those decisions about the treatment plan, we made them together. But I was really giving my recommendations. I probably gave you 5 different choices to begin with?

Currently, according to guidelines, there are a lot of different ways that you can treat ovarian cancer. Intravenous chemotherapy is the cornerstone of treatment. You were treated with paclitaxel, carboplatin, and bevacizumab, which is an option. Another option is chemotherapy, alone, every 3 weeks. Or, you can do this dose-dense approach where you do paclitaxel weekly. You don’t have a break. You can interject other drugs, other than paclitaxel, such as docetaxel. Some individuals might use liposomal doxorubicin.

 We talked a little bit about intraperitoneal chemotherapy and which patients are appropriate candidates. We didn’t do intraperitoneal chemotherapy at the beginning because you weren’t what’s called “optimally debulked.” But after chemotherapy and that second surgery, then you were optimally debulked.

 Exactly. But that was confusing, right? So, it’s important for patients to know about their options. That was a long discussion that we had in the clinic. It was probably 30, 45 minutes long. And then we talked on the phone, too.

 Yes, and I went home and looked everything up online just to see what would be best for me.

 It’s all about the different treatment options and deciding what’s right for you, as a patient. Like I mentioned before, you were young and healthy, otherwise really fit. Somebody who is not as fit may not be as good a candidate for surgery. Then you need to think about other options like chemotherapy, first, to make them stronger and to get their cancer under control. And then, surgery.

 Right. The big question is, do you do the chemotherapy, first, and then the surgery and more chemotherapy? Or, do you do primary debulking surgery first? We like to make that decision. In your situation, we did the laparoscopy procedure because you were so symptomatic. That’s a really important thing that patients should ask their doctors. “Which one’s better for me in terms of the sequence? Is it chemotherapy, first, or surgery first?” And, “How do we go about this?” In terms of that whole treatment process, what were your biggest concerns?

 I think my biggest concerns happened when I started hearing statistics. They were disconcerting to me. You mentioned Avastin (bevacizumab). Statistically, how much longer do patients live with it, as opposed to without it?

 You may not remember me saying this to you, but my classic line is, you have to be careful how you evaluate those studies. It’s a number. The patients that were included on a study might not be just like you. Some of the other studies that were done with Avastin were done in women who had different types of disease. Maybe it was more advanced than in your situation. Or, maybe there’s something different with the patient. So, I take those numbers with a grain of salt. As an individual, your story is going to be your story. We don’t know where things are going to be on that spectrum.

 Right. And remember, that’s a median number. They give you this number that’s in the middle, but there’s a bell-shaped curve, right? You could be on this long side of the curve, which is what you aim for.

 Right. I think that’s important to understand.

 And it’s hard to bring up those questions about prognosis. Some doctors have a hard time bringing it up. They wait for the patient to give the cue, but the patient really doesn’t know how to bring up those questions either.

 That’s hard. And doctors don’t really know.

 Some types of cancers, like pancreatic cancer, for instance, don’t have as good of a prognosis. It’s a tighter period of time, in terms of how long they’re going to survive. But in ovarian cancer, you see women surviving anywhere from 24 months up to 10 plus years. It really has to do with their own tumor biology as well as their own medical issues. Those variables help make that determination on how well they respond to chemotherapy.

Making Treatment Plans Together

 We did it right away. We talked about it right away.

 Right. I’ve had some physicians say to me that they don’t talk to their patients about genetic counseling when they’re initially diagnosed because they don’t want to worry them. They feel like it just adds another wrinkle of concern. When I brought up genetic counseling to you, very early on in your diagnosis, did that concern you?

 No, it didn’t concern me. It’s something that I had never even heard of before. I didn’t know that there was a 

 mutation or what that meant. For me, to get the testing done, it was more beneficial for my long-term survival. It was definitely something I wanted to do and I’m glad I did it.

 Right. Right away, we found out that you were 

 And that had implications for your family too, right? You talked to your kids. How did that conversation go?

 It went over very well, actually. They didn’t know what it meant either. It took a little while for my daughters to get it done. They just kept putting it off and putting it off. But they’re both negative.

 It’s very exciting. That was good news to hear.

 Right. And I’ve had patients in whom one of their children was positive for the mutation while another was negative. For the child who is positive for the mutation, it can help them make some decisions about having children. There’s certain things that can be done. Medical professionals can do selectivity for embryos that don’t have the mutation.

 There’s so many reasons to get tested, right? We were able to get you tested and get some information about your tumor biology and prognosis. And from your testing, we said, “Hey, there might be drugs available to you in the future.” And then, testing your family and making a difference for them, long term.

Reasons to Get Genetic Testing for BRCA

 Michelle, you did great for a while. Things were looking wonderful. I saw you for a few surveillance visits and I felt like you were getting your energy back, which was good. Then, a year later (2015), you had a documented recurrence based on imaging. And your CA-125 level started to creep up. At that point, we had a conversation about what the next steps were. But I think we’d also discussed, when you completed treatment, the high recurrence risk? In patients with ovarian cancer, their relapse rate is about 70%.

 I always have a hard time at the end of treatment, for that first-line, having that discussion. You want to be honest about the high relapse rate, but you also want to instill hope.

 Right. How did you feel, at that moment?

 Devastated. It’s devastating when you hear that your cancer is back. But there’s no cure. And so, it’s to be suspected. So soon? No. I wasn’t expecting it to come back so soon.

 Yes. You explained that to me that when you have the 

 mutation, it actually helps your cancer.

 It does help your cancer. It doesn’t make sense. That’s the huge paradox, right?

 It increases the risk of someone having cancer but, at the same time, it makes the cancer more susceptible to the chemotherapy. And that goes into the science about what 

 proteins do. They’re involved in DNA repair. They’re involved in a specific type of DNA repair that’s the most efficient one. And there’s all of these different pathways to repair DNA.

 Yes, it is very fascinating. But the whole “it doesn’t make sense” thing, it totally makes sense that it doesn’t make sense.

 To you, it makes sense. To me, it doesn’t make sense. But I trust you anyway. So, I’ll trust you on that.

 Right. It’s a really weird phenomenon. So, at the time that you had recurrence, we talked about different treatment options. I don’t know if you remember.

 I do. There were a couple of clinical trials available.

 We’re really fortunate, at our practice, that we have so many clinical trials that we can offer to patients. In your situation, we chose to do treatment off of a clinical trial. We talked about different chemotherapy options and adding back in the bevacizumab.

 At that point, there had been some information about bevacizumab improving disease control if you added it back with the chemotherapy. Then, you did what’s called maintenance bevacizumab. Just recently, there was a study published, GOG-213, on adding back bevacizumab. Not only did it improve disease control, but it also helped improve overall survival. We discussed that a little bit. I think it’s about a 5- to 6-month improvement in overall survival. So, in your situation we’re like, “Yes, we think you’re going to respond to these drugs again because you did so well the first time around. We’re going to add the bevacizumab in, again, because you really did quite well with that and didn’t have a lot of side effects.”

 No, I really didn’t. It was a nice time for me, on treatment, then.

 The other thing that I talked to you about was, if you’re going to start chemotherapy again, there are different backbones that you can use. I don’t know if you remember this conversation.

 There’s paclitaxel, carboplatin, gemcitabine, and liposomal doxorubicin. They’re all given on difference sequencing schedules, or different administration schedules, and they have different side effects. And so, that’s another area where it is really important to have that conversation with the physician that’s taking care of you. The treatment decision that you ultimately go with really depends on patient characteristics and side effects from past treatment. You had not had too many side effects on the prior treatment.

 No. I had abdominal cramping and some nauseous moments.

 What about peripheral neuropathy? That’s a big one for a lot of people. That’s a numbness and tingling in your finger and toes.

 I had it a little bit in my feet. But no. And, of course, the bloating. I’m still dealing with the bloating and the fatigue. The fatigue is another big thing that I’m dealing with, right now, from treatments. And chemo brain.

 Chemo brain is a fascinating issue. It’s real.

 I didn’t think it was, but I’m experiencing this. I don’t know if it’s old age or if it’s chemo brain, but I think it’s a combination of both probably.

 It’s a combination of both. I think you’re absolutely right. But I think that the chemotherapy certainly accelerates the process. They’ve done studies. There’s objective findings in terms of having people do these scoring tests. Yes, your brain doesn’t work as well after chemotherapy. You’re not alone, and everything you’re feeling is real.

 One of the things that I wanted to get back to is peripheral neuropathy. You were lucky that you didn’t have that, horribly. About 20% of patients will have this residual peripheral neuropathy. It can really be problematic. In some patients, it can be really severe. It affects their ability to walk, or button up their clothing, or do things that they love to do, especially if they’re interested in art work or crochet.

 So, if someone is experiencing peripheral neuropathy, they definitely need to tell their doctor. You can do things like a dose reduction, or hold therapy until their symptoms improve, or treat with a different drug if it’s that bad. There’s even some vitamin therapy that you can choose to do, too.

 I haven’t talked to you about this, but I found this new vitamin cocktail. I was at a meeting and one of the nurses there talked about her patient who had started herself on this vitamin cocktail. It really helped with the peripheral neuropathy.

 For my patients who are struggling with that, I give them this vitamin cocktail. It’s 5 different vitamins. And then, there’s this other thing, called “Scrambler Therapy,” that’s done at some centers. I believe it’s still experimental, but some of my patients have had this done. I think it involves the TENS unit.

There’s really a strong need for innovative ideas to try to prevent peripheral neuropathy. But in your situation, it wasn’t problematic. Therefore, we went back to treating with the paclitaxel, carboplatin, and bevacizumab. You did well, in terms of getting a partial response?

 I think so. For quite a few months, I think it was working.

 Right. And then we did maintenance bevacizumab for quite some time, too.

Talking About Recurrence Risk in Ovarian Cancer

Now we’re in a situation where we are doing maintenance treatment in the second-line setting. I want to back up and talk about how you made that decision to continue with maintenance bevacizumab versus changing to another drug if you have just a partial response. As a physician, when I’m considering maintenance treatment in that situation, if somebody has a complete response or a partial response, I think it’s very reasonable. If somebody has progressive disease, then you might make a switch to the right chemotherapy option. But now we have another option, PARP inhibitors. If somebody has a 

 mutation, that’s an option. It could be an option that opens up another situation. So, this gets into the whole situation of, what’s maintenance and what’s treatment? As a patient, do you feel like that’s difficult to understand? Or, how do you keep those 2 apart?

 No. They kind of overlap, a little bit. Like you said, I’m on a PARP inhibitor now. This is treatment, but it’s also maintenance for me, right?

 Well, you’re on it for treatment, but you have definitely responded.

 It’s kind of like treatment, now, because I am doing so well on it. So, it overlaps a little bit.

 I agree with you 100%. I think it’s hard for some people to tease that out. If somebody has a complete response in that situation, and even a partial response, some people lump this together under the maintenance. Other people will say, “Hey, wait! You have a partial response, you’re treating cancer, and that’s treatment.” Or, they look at it as, even if you have a complete response, you still have cancer there. We know it’s going to come back, quickly. That’s still treatment. So, the lines are blurred.

 But they’re important distinctions because some of the FDA approvals for PARP inhibitors are treatment approvals, and others are maintenance approvals. I like the way you think about it though. I think that’s good. So, you had a partial response to chemotherapy. We kept you on the bevacizumab for quite some time. You were tolerating that well. You had some issues with your blood pressure?

 For about 6 or 7 months, my blood pressure was a little high on that. I think that’s why we stopped it.

 Actually, you progressed. We actually had to work, a little bit, to get your blood pressure under control. But we were at a point where it was stable. So, we were OK with that.

 And now, it’s under control. I’m not on blood pressure medication or anything right now.

Deciding Whether to Continue Treatment

 Michelle, we were talking about some of the exciting new drugs that are available in ovarian cancer, and you’re on a PARP inhibitor. I want to share some of the decisions that we went through in terms of deciding when to use a PARP inhibitor for you, and which one. I want to go back to when you finished your second-line treatment of chemotherapy. You were on bevacizumab, and we did maintenance bevacizumab. That was actually a while ago. I don’t know if you realized this at the time, but none of the PARP inhibitors had been approved for maintenance yet. So, it wasn’t even an option that came up for us at that time.

 Yes, I remember that. I think it came out in December of 2016?

 Now, it is an option. If we were to go back in time, would our decisions be different?

 Yes. I’m just glad that it came out when it did.

 Right. Right now, there are 2 PARP inhibitors that are approved in the maintenance situation. Those are olaparib and niraparib. And the approval for those PARP inhibitors, in that maintenance situation, when a patient had platinum-sensitive chemotherapy and they responded to their chemotherapy with either a complete response or a partial response, is for all-comers. So, you don’t have to have a mutation.

 germline mutation, right? In this situation, any patient who is platinum sensitive, who responds to that chemotherapy, can go on a PARP inhibitor for maintenance treatment. And for somebody who has had a 

 mutation, with either a germline mutation, like you do, or a mutation that is just in a tumor, the benefits, in terms of disease control, are pretty outstanding. We’re talking not just twice as long, but almost 3 or 4 times as long.

 Yes, it’s pretty dramatic. I’d give you the numbers. It doesn’t even really pop out, in terms of the improvement on the curves. We’re talking 19 versus 5 months, or 16 versus 5 months.

 There’s some differences in terms of how you assess that data. But the bottom line is, it works, right? If somebody doesn’t have one of those mutations, but let’s say they have another mutation that’s associated with homologous recombination defects, there’s still a benefit. It’s not quite as strong, but I think it was a 6- to 9-month benefit in those situations. And again, you have to take these numbers with a grain of salt. The bottom line, though, is that it does work in that situation. And then, if somebody doesn’t have the mutation at all, the benefit is less. It’s about a 3-month range of disease control. You have to be careful with the numbers because of other things, such as the hazard ratio. You’re basically decreasing the risk of disease from coming back by in some cases 40%, if somebody doesn’t have the mutation or the homologous recombination defect. I gave you a lot of information.

 But as a patient, what do you think of when somebody tells you all of that information?

 As a patient you go by statistics, a lot, because you want the best treatment that you can possibly get. So, if statistics are looking good, in my favor, then that’s my decision. That’s what I base my decisions on.

 mutation, it would look really good to get one of these drugs. They weren’t available for you at the time. We did bevacizumab, which I think makes a lot of sense given the data. You progressed. At that point, we did talk about the fact that there was a drug available called rucaparib. That’s a different PARP inhibitor. Rucaparib is one of the PARP inhibitors that’s now been approved for treatment, right?

 The other PARP inhibitor that’s approved for treatment is olaparib. I just want to go over this again because it’s very confusing.

 There’s 3 PARP inhibitors. They have different indications from the US Food and Drug Administration regarding when you can use them and in which patients you can use them. The maintenance indications are for niraparib and olaparib, and the treatment indications are for olaparib for patients who have a germline mutation, only.

 Yes, like you. And, these patients have had at least 3 prior chemotherapies. And then, the other one is rucaparib. Rucaparib is for patients who either have a germline mutation or somatic mutation. That means a mutation that is just in the tumor. They didn’t inherit it from a parent. They have a de novo mutation in the tumor, and have had 2 prior chemotherapies. You can actually use rucaparib sooner than you can use olaparib. I think at some point, these distinctions are going to be a wash and all of these PARP inhibitors are going to be approved across the board.

 But right now, how we make those decisions is really based on the indication, the tumor, and the genetic germline mutation biomarker. So, it’s really important that patients have the conversation with their physician about which of these PARP inhibitors, if any, may be appropriate for them. That’s one part of the treatment decision, right? Then, the other part is a side effect profile. In your situation, we had rucaparib as an option. We went for it.

 It actually became available right when I needed it.

 What has your experience been with rucaparib, so far?

 The side effects have been minimal. I have drainage in my eyes and my nose, and abdominal cramping once in a while. Fatigue is still there, but that’s pretty much it. I’m doing really well on it. Sometimes, I get nauseous and I can’t eat.

 How do you feel on the drugs, as compared to everything you’ve gotten throughout this whole experience?

 It’s the best I’ve felt in over 4 years. My quality of life is really good right now.

 That really strikes me. It’s the best you have felt in 4 years. That includes the time that you came off of any treatment and you were in your first remission. This is the best you have felt.

 Yes, this is the best, even compared to when I was in remission for 6 months. That’s how well this drug is working for me.

 Right. I think that for some patients, these drugs could potentially represent a cure for someone with platinum-resistant or platinum-sensitive recurrent ovarian cancer. They’ve had some patients on these drugs, long-term. And one of the studies, Study 19, which is an olaparib study, now reveals data going out 5 years. There’s a few patients that are long-term survivors.

 Michelle, going to back to when we talked about starting on a PARP inhibitor, we knew that option was potentially coming months before it was even available. I know that your daughter even knew it was coming?

 Yes. She works for a clinical trial company.

 She’s very smart and she was very interested in PARP inhibitors for you. But not everybody knows about these drugs, right? Maybe some of our patients don’t know about them. Maybe some of their doctors don’t know about them either. I personally think the PARP inhibitors and their approval in ovarian cancer is the most exciting thing we’ve had happen in years.

 It’s transformative. So, I would like to shout out to all patients that they should have PARP inhibitors on their radar. Ask your doctor about them. See if you’re a candidate for these drugs. And then, when you’re making decisions about which drugs to use, discuss the side effect profiles, how many pills you have to take, and, obviously, the cost. Would you add anything to that?

PARP Inhibitors: Deciding Among the Available Agents

 If all of these PARP inhibitors are available across every indication, how do you choose which one to use?

 And of the PARP inhibitors that are available for those indications, we talked about maintenance versus treatment. And those lines are blurred, right? How do you choose which one to use? And so, it comes down to the side effect profile.

You’re doing really well on rucaparib. You are tolerating it well. All of these drugs are associated with some nausea, which you’re experiencing. And for some of the drugs, it’s been worse. The olaparib medication, which came out first, was in capsule form. Patients had to take 16 capsules a day.

 I did hear about that. That’s a lot. I take 2 pills in the morning and 2 pills at night. That’s my chemotherapy.

 If I had to take 4 pills in the morning, I would be nauseous. I feel like some of the nausea that was initially reported was probably just due to how much people were taking. Then, we talked about the fact that people had 3 prior chemotherapies before they could even go on the drug. Maybe they had more disease burden? They may have had more gastrointestinal symptoms that made it hard. So, what we often talk to our patients about is making sure they eat something. They just need to eat a little something. Maybe a light amount of food.

 Perfect. They should eat something about 30 minutes before they take the medication. Did you find this to be helpful?

 And hopefully we did our job when we first gave you the medication. We talked to you about nausea and how to control it, right?

 Yes. I take olanzapine. It works great for nausea.

 Right. That’s an interesting drug. It’s an old drug, but it just came out for managing nausea. So, we’ve been using that a lot. It helps with the PARP inhibitors. There’s one PARP inhibitor specifically, olaparib, that you can’t take a really common nausea medication for because it induces one of the enzymes that’s involved in that drug’s metabolism. So, you need to be careful. But olanzapine has been really useful to help with vomiting.

 Yes, it helps me a lot. I take 1 capsule at night and it takes care of me for the whole next day.

 Fantastic. Other patients have some different types of side effects with these various drugs. I want to talk about some of the more common ones and get your thoughts on those?

 Niraparib, the PARP inhibitor, is only given once a day. That’s nice. It’s easier. But its side effect profile is a little different. It is associated with more thrombocytopenia, grade 3 or 4 thrombocytopenia, which means that the platelet counts are getting lower. Typically, this is not clinically significant. I personally haven’t had anybody experience bleeding issues on it, but we watch them really closely. You might have to dose reduce. You have to do weekly Complete Blood Counts. I typically do this for about 8 weeks. Not everybody does that, but I do it to make sure that you stay on target. If somebody is doing great, you can back off. This happens in about a third of patients. All patients are at some risk for anemia with any of the PARP inhibitors.

 I think I have a little bit of that going on.

 It’s about 20% to 25%. We watch for that closely. I don’t typically transfuse unless you absolutely need it. And we can evaluate for other causes of anemia, like B12 and folate. Most of the time, it is due to the drug. If somebody has a hemoglobin less than 8, you can stop the drug, do other supportive measures, and then dose reduce if you need to. Rucaparib and niraparib can also reduce your absolute neutrophil count.

 Rarely have I seen it cause such bad problems compared to when you’re on chemotherapy, but it’s something that we evaluate for. The rucaparib drug can also be associated with a slight increase in creatinine because of the way it’s involved. It’s an off-target effect.

 I know. I remember that my levels were a little high last month.

 Yes. And so, we watched it closely. We didn’t intervene though, because they were just up slightly. Most of the time you see this early. Then, it stabilizes out.

 Right. And you’ve been on it for about 5 months?

 Around 5 to 6 months now. I think I started it in the middle of June.

 Most of the time, I just follow those numbers and don’t have to intervene at all. I think it’s really important that physicians understand that can be something that you see with this drug. It doesn’t mean a dose reduction is necessary, unless you have severe grade 4 toxicity. But you need to evaluate for other causes. Yours was so low that we didn’t really pursue that. But if somebody is really worried and the creatinine starts to rise quickly, it is important to think about other causes of blockage of the ureters. Check a renal ultrasound. Have it on your radar. What else can be going on that causes somebody to have an increase in their creatinine? Typically, it’s not due to renal function issues.

 Yes, that was my first thought when I heard about it.

 The other thing is, it can cause your liver enzymes to go up slightly. But it’s not liver injury, per se. It is just something to monitor. And again, you don’t have to dose reduce if it’s only a slight elevation. It’s not associated with liver dysfunction, which is great. Then there’s different types of side effects like rash and sunlight issues.

 Right. For the most part, we see mild side effects. Olaparib is predominantly associated with nausea, but I do think that was capsule related. Now that they’ve moved to this new tablet formulation, I think it’s improved. And then, anemia is probably the most common. But with olaparib, and this is kind of a weird fun fact, you want to avoid grapefruit and Seville oranges.

 Yes. Some people are huge citrus fans. For others, it doesn’t really matter to them too much. But those are all kinds of things that people take into account.

 But those are all things that people have to take into account when making these decisions.

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