Treating recurrent ovarian cancer requires a new perspective on the disease and the objectives of therapy, according to Deborah K. Armstrong, MD, assistant professor of gynecology and obstetrics at Johns Hopkins University School of Medicine. With initial disease, the goal is to prevent recurrence. "But once we have documented a relapse for our patients, we have to shift gears a little bit," Dr. Armstrong said at a recent teleconference entitled, Recurrent Ovarian Cancer: State-of-the-Art Treatments. "What is most helpful is to actually think about treating recurrent ovarian cancer as a chronic disease, just like you’d treat diabetes or high blood pressure."
Although recurrent ovarian cancer may go into a remission, she continued, "it’s never really going to go away completely." When remission is not possible, the goal of treatment becomes stopping or slowing the spread of cancer cells. As with other chronic diseases, the emphasis of treatment is on delaying progression of the disease rather than on eliminating it altogether. "We’d like to see a response, but we recognize that for some patients, particularly patients whose disease was growing quite quickly, stable disease is a benefit." She added, "Many of our treatments today have a much higher stable-disease rate than they do a response rate…We’d like to be able to put everybody into another remission, but we recognize that we can’t always do that."
The treatment of any chronic disease requires that a physician understand the natural history of the illness. In addition, physicians must recognize that the progression of disease and its manifestations will vary from patient to patient. This is also true with recurrent ovarian cancer.
The key to treating recurrent ovarian cancer is to maximize the number of agents used while minimizing treatment-related symptoms, Dr. Armstrong said. This is best accomplished by juggling the order of the chemotherapies used. In particular, the physician must carefully consider how any treatment decisions made now will affect management of the disease later. "We need to anticipate impending decision points," Dr. Armstrong said. "For example, when seeing a patient, I’m thinking: If I treat that patient today, what will my choices be? If I treat that patient 6 months from now, what will my choices be then? And [those choices] are sometimes quite different."
Four Key Drugs
Four drugs have been shown to be effective in patients who relapse within 1 year of initial treatment with platinum-based drugs and taxanes. These drugs are topotecan(Drug information on topotecan) (Hycamtin), liposomal doxorubicin(Drug information on doxorubicin) (Doxil), etoposide(Drug information on etoposide), and gemcitabine(Drug information on gemcitabine) (Gemzar). "I tell patients that under ideal circumstances, we’re going to use all of these agents at one time or another," Dr. Armstrong said. "The question isn’t which one of these agents to use, but what order we should use them in."