New post-chemotherapy maintenance treatment options for ovarian cancer have emerged in recent years. Dr. Maurie Markman explains and takes questions on maintenance therapies for ovarian cancer in our 4th annual Joan Sommer Educational Program.

1. ®IPB 2018
Ovarian Cancer “Maintenance Therapies”
For Long Term Survival
September 25, 2018
Maurie Markman, MD
President, Medicine & Science
Cancer Treatment Centers of America
Clinical Professor of Medicine
Drexel University College of Medicine

2. ®IPB 2018
WHAT IS “MAINTENANCE THERAPY”?
Goal: To maintain an existing response
• Trial terminology - prolong PFS (progression-free survival)
Inconsistent with:
• Intensification of treatment to achieve a favorable outcome (“consolidation”)
Consistent with:
• Favorably impacting overall survival (may be difficult to “prove” in a randomized trial due to
post-trial rx.)
• Maximizing quality-of-life
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3. ®IPB 2018
WHY NOT SIMPLY ROUTINELY CONTINUE THERAPY IF
RESPONDING TO TREATMENT?
Older experience with alkylating agent therapy of ovarian cancer (documented 10% risk of acute
leukemia with extended > 18 months of treatment)
Long-term cumulative side effects
• cardiac (anthracyclines)
• peripheral neuropathy (platinum agents, paclitaxel)
• renal dysfunction (cisplatin)
• fatigue
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4. ®IPB 2018
THEREFORE, WHY EVEN CONSIDER “MAINTENANCE
THERAPY” IN OVARIAN CANCER?
• High objective response rate to platinum-based chemotherapy in ovarian cancer
(approximately 80% in the front-line setting, lower in second or later lines of treatment), but
also high risk of recurrence
• Thus, the goal is to extend the duration of PFS following the attainment of a response
(measurable disease, symptoms) and also favorably impact overall survival
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5. ®IPB 2018
WHAT IS THE EVIDENCE OF THE CLINICAL VALUE OF
“MAINTENANCE STRATEGY” IN OVARIAN CANCER?
• Several trials comparing 5 or 6 versus 10 or 12 cycles of platinum-based chemotherapy-
no evidence of benefit
• Non-randomized experience with prolonged paclitaxel suggestive of possible benefit
• Phase 3 randomized trial examining 12 cycles of single agent paclitaxel following front-line
chemotherapy - improvement in PFS but high risk of clinically-relevant neuropathy
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6. ®IPB 2018
• Front-line (2 trials) – following carboplatin/paclitaxel
• Platinum-sensitive recurrent disease – following > 4 cycles carboplatin/paclitaxel or
carboplatin/gemcitabine
• Platinum-resistant disease – in combination with:
₋ Single agent weekly paclitaxel
₋ Single agent weekly or q-3week topotecan
₋ Monthly pegylated doxorubicin
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BEVACIZUMAB “MAINTENANCE” IN OVARIAN
CANCER (PHASE 3 TRIALS)

7. ®IPB 2018
PARP INHIBITOR “MAINTENANCE” IN OVARIAN
CANCER (PHASE 3 TRIALS)
• 3 agents FDA-approved as “second-line or later” “maintenance therapy”
• Niraparib
• Olaparib
• Rucaparib
• Improvement in PFS – greatest in BRCA-mutation positive patient subgroup, but also
observed in BRCA wild-type population
• Front-line maintenance trial data - pending
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8. ®IPB 2018
WHICH STRATEGY IS “OPTIMAL” FOR AN
INDIVIDUAL PATIENT?
• Patient choice/decision
• Considerations in this patient-directed decision
₋ Observed tolerability to bevacizumab during active treatment in the individual patient
₋ Presence or absence of a BRCA mutation (germline or somatic)
₋ Patient desire to discontinue parenteral therapy or preference for oral therapy
₋ Cost/insurance coverage/co-pays (parenteral versus oral therapy)
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9. ®IPB 2018
ADDITIONAL ISSUES WITH “MAINTENANCE”
STRATEGY IN OVARIAN CANCER
• Long-term toxicities with extended treatment and prolonged survival
• Low-grade side effects (e.g., nausea, fatigue) which would likely not be considered to be
excessive during active treatment phase (delivered over 4-6 months) but might be
unacceptable if occurred frequently (e.g., daily) with therapy delivered over a far more
extended (“maintenance”) period of time (e.g., 1-5+ years)
• Cost of therapy
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