Angeles Alvarez Secord, MD, recalls how she explained treatment options to her patient, Michelle Berke. Michelle offers her perspectives on the difficulty of processing the information.
PUBLISHED December 27, 2017
Angeles Alvarez Secord, MD: 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.
Michelle Berke: I’ve heard of that.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: That’s when you put the port in. Yes.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: Yes, and I went home and looked everything up online just to see what would be best for me.
Angeles Alvarez Secord, MD: Right.
Michelle Berke: And your recommendations were spot on.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: And then go back, yes.
Angeles Alvarez Secord, MD: 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?
Michelle Berke: 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?
Angeles Alvarez Secord, MD: 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.
Michelle Berke: Everybody is so different.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: I like that. I like that curve.
Angeles Alvarez Secord, MD: Right. I think that’s important to understand.
Michelle Berke: OK.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: That’s hard. And doctors don’t really know.
Angeles Alvarez Secord, MD: 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.