Maurie Markman, MD: Justin, what’s your initial approach to the management of patients with ovarian cancer with advanced disease? Justin Chura, MD: So, we talked about the cornerstones of treatment, which are surgery and chemotherapy. And the first question is, which are we doing first? And that’ll be based upon several factors. One is the overall condition of the patient, not just physically or from a nutritional standpoint, but also mentally, or spiritually, as Anya alluded to. What is the patient ready to assume? What can she take on at that time?
And then, there are other variables that come into play, in terms of the extent of disease present on imaging. Are there some signs that indicate that we might be able to resect all of the cancer, or that the operation might be an incomplete operation? There are no great predictive models for that, so we can’t predict that with 100% accuracy. But we do know that there are some findings on imaging, or sometimes, if we do a diagnostic laparoscopy, that can help us predict where we should triage our patients first, whether it’s to chemotherapy or to surgery. And then, once we make that decision, if it is surgery, which is oftentimes the bias, the goal is then to remove all of the disease at that time. That can then be an extensive operation, where we can remove a segment of intestine, or a spleen, or a portion of the liver to really get to the point of no obvious visible cancer remaining. So, those operations require stamina as well as patients’ willingness to get through that. Maurie Markman, MD: One of the discussions, today, is about the potential role for the so-called neoadjuvant chemotherapy. My own perspective on that is really that it is about the surgeon. And just as you said, as a medical oncologist, I don’t operate. So, I would ask you, do you believe you can remove the gross disease? If the answer is yes, that’s an absolutely reasonable approach. And your statement is, “You know, that’s going to be tough,” for whatever reasons, either where the disease is or concerns about the comorbidities. And chemotherapy seems like a reasonable approach. There’s obviously differences of opinion as to which patients fall into which category. But there’s currently data that suggest that patients who get chemotherapy first can do quite well. Justin Chura, MD: Correct. There’s been several studies that have come out to show that doing chemotherapy first does not appear to harm the overall survival. I don’t have a dogmatic or gospel approach to which is the paradigm that’s best. It really is about the patient in front of me and what we think will get us the best results at the end of the day. And so, there has to be, I think, some flexibility in terms of one’s viewpoint or standpoint on how you’re going to treat the disease. You’re absolutely right. If I assess and determine that I don’t think that I can achieve a complete resection, whether it’s based on patient’s overall health or whether it’s based upon where the disease is, then those are the patients in whom we do triage to chemotherapy. This gives us a little bit of a trial balloon to see if their disease is responsive to chemotherapy. And that helps us, then, to go forward and know whether there will definitively be a role for surgery. Maurie Markman, MD: Looking back at Anya’s 15-year journey, what has been her therapeutic journey? Then, I’m going to turn around and I’m going to ask for Anya’s perspective on that as well. How has she been treated and managed? Justin Chura, MD: One of the conversations we have, early in the course, is what to do when there’s a recurrence of the cancer. The risk is up to 80% for patients because they may have presented with advanced stage disease. So, we know that most of our patients do recur. There is that small subset that doesn’t, and we certainly have to approach our therapy and our treatment plan as if we’re aiming to get them into that minority. But the majority recur and we talk about recurrence. The treatment paradigm shifts from talking about cure to more of, how are we going to treat and manage this disease?
When we start down that journey, we know we’re always going to be vigilant and there’s always going to be some type of follow up, or surveillance. And then, there will be periods of very intense treatment. Anya’s had periods where she’s had an operation followed by chemotherapy. Or, an operation followed by a clinical trial of a vaccine therapy, that we had done for her. And so, during those periods, it’s very intense. We are compromising quality of life for those timeframes, to some extent. But fortunately, we’ve also been able to achieve remissions and intervals where Anya’s not on therapy and she’s certainly living her life. Then, she’s following up with us. We’re continuing to do our surveillance. We’re continuing to talk about what to do when and if. And the interesting this is, since her last operation, we’ve had 3 or 4 new therapies approved that could potentially impact her care. PARP (poly [ADP-ribose] polymerase) inhibitors, as well as an immunotherapy have been approved, depending upon her tumor’s characteristics. It’s amazing, from that standpoint, if you think about it. Maurie Markman, MD: Anya, you’ve used this term “journey,” when describing your 15-year term with cancer. I don’t know if that’s an appropriate term, but it’s been a number of years, and you’ve been through these various stages, from your initial diagnosis, to sitting with us today. How has your team helped to prepare you for the various steps along the way? Obviously, you’ve had surgery. You’ve had experimental therapies. You’ve had standard chemotherapy. How does your team work with you? How has all of that happened? Anya Khomenko: Of course, the first line of defense is my husband, who is on my team. Maurie Markman, MD: Absolutely, he’s the quarterback. Anya Khomenko: Absolutely. He’s of great support. He goes and he searches for new treatments. He constantly gives me hope when I’m down, and that happens. And, of course, second are my doctors, like Dr. Chura, whom I trust wholeheartedly. He’s been great and I can’t express enough how thankful I am to you, doctor.
Of course, it involves a lot more than just a physician or gynecologic oncologist. Cancer Treatment Centers of American employs a whole team of nutritionists, and naturopathic doctors, and even provides massages, which I didn’t use much, and other modalities. That’s very important as well as your own way of life, your regimen. I put myself on a rather strict, albeit enjoyable, regimen of diet and exercises, and I think I’m doing quite well. What do you think, doctor? Justin Chura, MD: I would agree with that. She just came back from China recently, where she spent a few weeks. Anya Khomenko: Yes, we did. Maurie Markman, MD: When you are talking about a new regimen, or new strategy, are there specific questions you ask, or you have asked, routinely, of each new strategy, that’s very important to you? In other words, something has happened. There’s a concern for a potential for another treatment. Dr. Chura may present it to you. What’s particularly important to you? Anya Khomenko: Actually, when I come to my doctor, I always have a list of questions. I do get prepared. I actually would tell everybody to do just that, prepare for your visit. And, of course, I go down the list with all of the questions. I ask about the questions of efficacy, of quality of life. I’m also interested in the whole regimen. Exercises, nutrition, and any other adjunct treatments that could be out there.