Therapy of recurrent ovarian cancer

Today, the therapy for recurrent ovarian cancer is determined by numerous factors. Unlike in earlier times, the length of platinum-free therapy intervals plays only a subordinate role.

State of the Art 2021

Today, the therapy for recurrent ovarian cancer is determined by numerous factors - from patient preferences to pre-treatment and genetic factors. Unlike in earlier times, the length of platinum-free therapy intervals plays only a subordinate role.

"The calendar used to be our most important tool in characterising patients with recurrent ovarian cancer," explained Prof. Dr. Andreas du Bois at the 11th International Charité Mayo Conference. He is Director of the Clinic for Gynaecology & Gynaecological Oncology at the Evangelisches Klinikum Essen-Mitte. "Today we see it in a more differentiated way: The decision for or against a platinum-based therapy is much more complex than looking at the calendar."

Calendrical classification of recurrences

Background: In the 1990s, treatment was strongly oriented towards the timeline. Corresponding indications can still be found in the guideline today, albeit in a much more differentiated way. Molecular biomarkers that predict a response to platinum do not yet exist, the speaker said.

Classification:

Strategies for platinum-resistant and platinum-sensitive relapses

Many patients already have experience with therapies. They should be asked about their wishes before any new treatment.

Patients with platinum-sensitive ovarian cancer recurrence should receive platinum-containing agents if there is an indication for chemotherapy. If platinum is unsuitable due to resistance, neither combination therapies nor endocrine therapies offer advantages over monotherapy. Numerous single agents are available to oncologists today. Combinations with angiogenesis inhibitors are also possible.

Surgical recurrence therapy

In his lecture, du Bois also addressed the importance of recurrence surgery in ovarian cancer. "Patients benefit from the complete removal of the tumor," the speaker explained. The goal should therefore always be a macroscopic complete resection.

Currently, there are no prospective study data with a high level of evidence. However, retrospective data speak for a benefit. Prof. du Bois hopes that the DESKTOP III study will provide further insights.

Therapy with PARP inhibitors

PARP inhibitors offer a new treatment option, says du Bois. If patients have high-grade ovarian cancer with recurrence and they respond to platinum, they should receive PARP inhibitors. The situation is somewhat different for patients with platinum-sensitive recurrence of BRCA-mutated high-grade ovarian cancer if they have a history of two or more platinum therapies. They may benefit from a PARP inhibitor as monotherapy.

The Charité perspective

Prof. Dr. Elena Ioana Braicu summarised in her lecture how patients with recurrent ovarian cancer are treated at the Charité in Berlin.

For women who have been pre-treated with PARP inhibitors, who have recurrences with BRCA mutations and who are in all likelihood platinum-sensitive, there are several options. Platinum-based protocols are used here, possibly in combination with angiogenesis inhibitors or with PARP inhibitors as follow-up therapy. In the case of back mutations, only sequencing remains to select suitable protocols.

If patients have already received angiogenesis inhibitors and PARP inhibitors, platinum-containing chemotherapies plus PARP inhibitors are a possibility if there are no back mutations. Otherwise, various platinum-free monotherapies remain as a way out.

The Mayo Clinic perspective

Dr. Matthew S. Block and Prof. Dr. William A. Cliby presented therapeutic algorithms of the Mayo Clinic. Angiogenesis inhibitors play a central role in platinum-resistant tumors; however, their use should also be considered in platinum-sensitive forms. If patients have already received PARP inhibitors, oncologists do not administer any further agents of this class. Otherwise, PARP inhibitors are the choice for maintenance therapy after platinum-based agents. Whether women benefit from surgical intervention is a case-by-case decision.

Reference:
11th International Charité Mayo Conference, Presidential Lecture, 07.05.2021

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