Angeles Alvarez Secord, MD, discusses the risk of recurrence of ovarian cancer with her patient, Michelle Berke. Dr Secord also explains how BRCA mutations play a role in the disease course and how she determines the best treatment option once cancer recurs.
PUBLISHED December 27, 2017
Angeles Alvarez Secord, MD: 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%.
Michelle Berke: That’s pretty high.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: And encouragement.
Angeles Alvarez Secord, MD: Right. How did you feel, at that moment?
Michelle Berke: 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.
Angeles Alvarez Secord, MD: I wasn’t either, because you’re BRCA1 positive.
Michelle Berke: Yes. You explained that to me that when you have the BRCA1 mutation, it actually helps your cancer.
Angeles Alvarez Secord, MD: It does help your cancer. It doesn’t make sense. That’s the huge paradox, right?
Michelle Berke: Yes.
Angeles Alvarez Secord, MD: 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 BRCA1 and BRCA2 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.
Michelle Berke: Fascinating.
Angeles Alvarez Secord, MD: Yes, it is very fascinating. But the whole “it doesn’t make sense” thing, it totally makes sense that it doesn’t make sense.
Michelle Berke: To you, it makes sense. To me, it doesn’t make sense. But I trust you anyway. So, I’ll trust you on that.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: I do. There were a couple of clinical trials available.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: Yes.
Angeles Alvarez Secord, MD: 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.”
Michelle Berke: No, I really didn’t. It was a nice time for me, on treatment, then.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: A little bit, yes.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: No. I had abdominal cramping and some nauseous moments.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: 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.
Angeles Alvarez Secord, MD: Chemo brain is a fascinating issue. It’s real.
Michelle Berke: 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.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: Good, that makes me feel better.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: I could see that.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: B12?
Angeles Alvarez Secord, MD: B12 is one of them.
Michelle Berke: Yes, I’ve heard that.
Angeles Alvarez Secord, MD: 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.
Michelle Berke: Oh, good.
Angeles Alvarez Secord, MD: 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?
Michelle Berke: I think so. For quite a few months, I think it was working.
Angeles Alvarez Secord, MD: Right. And then we did maintenance bevacizumab for quite some time, too.