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Strategies for Long-term Management of Recurrent Ovarian Cancer

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A panel of doctors and patients will discuss decision-making in the recurrent setting of ovarian cancer, including how to understand and consider options like chemotherapy, surgery, and clinical trials. Panelists include Dr. Jason Wright and Dr. June Hou from Columbia University College of Physicians and Surgeons, survivor/research advocate Annie Ellis, and others living with recurrence.

Published in: Health & Medicine
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Strategies for Long-term Management of Recurrent Ovarian Cancer

  1. 1. Ovarian Cancer: New Insights and Treatments Jason D. Wright and June Y. Hou Columbia University
  2. 2. Ovarian Cancer • 2015 ovarian cancer statistics o 21,290 cases o 14,180 deaths
  3. 3. 0%# 20%# 40%# 60%# 80%# 100%# 0# 5# 10# 15# 20# Stage&I& Year&since&diagnosis& 1980# 1990# 2000# 0%# 20%# 40%# 60%# 80%# 100%# 0# 5# 10# 15# 20# Stage&III0IV& Year&since&diagnosis& 1980# 1990# 2000# A.# B.# Outcomes for Ovarian Cancer • Survival is improving for ovarian cancer • 5 year survival: o 27% (1958-1962) o 50% (1999-2001) • Relative survival (1975 vs. 2006): – Stage I (HR=0.51) – Stage III-IV (HR=0.49)
  4. 4. Treatment of Ovarian Cancer • Surgery in combination with chemotherapy • Surgery –cytoreduction (debulking) • Neoadjuvant chemotherapy
  5. 5. Treatment of Ovarian Cancer • Adjuvant chemotherapy o IP chemotherapy o Dose dense chemotherapy • Chemotherapy for recurrent cancer o New agents o New combinations o Precision medicine
  6. 6. Clinical Trials in Ovarian Cancer Phase Study design Phase I Safety and toxicity Phase II Demonstrating some effect Phase III Demonstrating superior outcome compared to standard drug/treatment regimen
  7. 7. Regulatory Approval Bast RC, Thigpen JT, Arbuck SG, et al. Gynecol Oncol 2007;107(2):173-6.
  8. 8. Bevacizumab
  9. 9. Olaparib
  10. 10. Precision Medicine: the new era for ovarian cancer treatment
  11. 11. The Precision Medicine Initiative
  12. 12. • Traditional cancer care: One size fits all • Works great for some patients but not for others • Most medical treatments have been designed for the average patient • Precision medicine: Individualized therapy • Takes into account individual differences in the genetic makeup of patient’s disease • Transforming the way we treat diseases such as cancer
  13. 13. Precision Medicine has already transformed the treatment of lung cancer Survival benefit of 1.1 years was seen in patients with an oncogenic driver mutation who received targeted therapy compared to those without a driver mutation or targeted treatment
  14. 14. Applications: Offering tailored treatment strategies Providing early detection Prediction of response or toxicity Precision medicine can help to improve survival in women with ovarian cancer
  15. 15. New opportunities for Immunotherapy • PD1 / PDL1 inhibitors have been granted breakthrough FDA approval for PDL1+ bladder and NSCLC • Early phase clinical trials have shown promising results for inhibitors of PD-1 and PD-L1 in recurrent ovarian cancer patients with low toxicity • Clinical trials are ongoing for combination treatments and validation of response PDL1+
  16. 16. Taking advantage of the p53 mutation • Almost all epithelial ovarian cancers have p53 mutations, leading to defect in cell’s ability to repair DNA • Wee 1 inhibitor (AZD1775) combined with chemotherapy shows promise in patients with p53 mutated platinum- resistant ovarian cancer
  17. 17. Center for Precision Medicine For Gynecologic Oncology • Initiated fall 2014 • Comprehensive program to integrate genome-based knowledge into the treatment of gynecologic cancers • One of the first programs in the country Histology-based to molecularly-guided treatment
  18. 18. Ovarian Cancer clinical trials at CUMC Setting Agent Neoadjuvant / 1st line * GOG 3005 C/T +/- ABT888 1st recurrence * MORAB (plat sens) * GYN49 (plat resist) AZD1775 + Carbo/ Gemzar or weekly taxol 2nd recurrence * Janssen Doxil vs. Yondelis + Doxil 2-3rd recurrence CORAIL PM01183, PLD or topotecan Any prior therapy MEK162 + Letrozole IRB# Agent N4003 D53032b / MDM2 inhibitor N9701 Trastuzumab/Pertuzumab · Erlotinib · Vemurafenib · Vismodegib O0006 MGCD516 (Multi-target TKI) O2406 INCB2430 + Nivolumab IDO1 + PD1 O7762 Varililumab + Nivolumab CD27+PD1 PO559 MGCD265 cMET inhibitor MATCH / NCI 73 genes Phase 1B-III Phase 1
  19. 19. Precision medicine-based clinical trial
  20. 20. Precision Medicine is the future of clinical therapy in cancer care • Number of agents available to target molecular drivers in cancer is rapidly increasing • Treatment algorithms based on molecular targets are already improving outcomes for some patients • The road to true ‘personalized medicine’ is not accessible to all patients. Need to advocate and fast track advances for ovarian cancer • Quality of life should be an important focus
  21. 21. Strategies for Long-Term Management of Recurrent Ovarian Cancer September 10, 2015 Annie Ellis Ovarian Cancer Survivor/Research Advocate
  22. 22. Annie Ellis  11-year Ovarian (2 recurrences) and 4-year Breast Cancer Survivor  FDA Patient Representative  CDMRP Ovarian Cancer Research Program Integration Panel  Roswell Park Ovarian Cancer SPORE Patient Representative  2014 AACR Scientist↔Survivor Program  Ovarian Cancer National Alliance ◦ Research Advocate ◦ Formerly on Special Programs (Education) and Conference Committees ◦ Conference Speaker; Survivors Teaching Students®  SHARE ◦ Helpline Peer ◦ Former Peer Support Group Facilitator ◦ Presented at SGO 2008 “The Patient’s Perspective”  NY Presbyterian-Columbia Woman to Woman Peer  Ovarian Cancer Research Fund: Clinical Trials Video and Symposium Speaker  2013 Congressional Briefing on Ovarian Cancer for Society for Women’s Health Research (SWHR)
  23. 23. Journal of Gynecologic Oncology, November 2014, Volume 135, Issue 2, Pages 261–265
  24. 24. The work is not over until everyone has a chance to have a lasting and meaningful Dance with NED. No Evidence of Disease FDA Ovarian Cancer Endpoints Workshop Co-sponsored by FDA/SGO/AACR/ASCO September 3, 2015 Ovarian Cancer Survivorship Survey (August 2015)
  25. 25. My journey  2006 OCNA Ovarian Cancer National Alliance Conference 2008 SGO  SHARE Presentation The Patients’ Perspective
  26. 26. Joan Sommer: “Surviving and living with ovarian cancer is not an arbitrary period like five years. It is an everyday thing where you wake up, take a deep breath in spite of your fears and pain, and find a way to take your place in the world” “Surviving cancer is not a place you strive for in the distance. It is here and now. You are in it. It is up to you to be part of it, to find your hope.” “Hope is falling asleep and expecting to wake up each day in spite of what you might have heard. It is thinking about the possibilities not probabilities. It is preparing to die but expecting to live.” “When faced with uncertainty there is nothing wrong with hope.”
  27. 27. Coping Images: various internet sources
  28. 28. Coping—Professional Support Major Depression • Feeling sad most of the time. • Loss of pleasure and interest in activities you used to enjoy. • Changes in eating and sleeping habits. • Nervousness. • Slow physical and mental responses. • Unexplained tiredness. • Feeling worthless. • Feeling guilt for no reason. • Not being able to pay attention. • Frequent thoughts of death or suicide. Cancer-related Post-Traumatic Stress • Repeated frightening thoughts. • Being distracted or overexcited. • Trouble sleeping. • Feeling detached from oneself or reality When to get help: ►Any time you feel you need assistance ►When mood/feelings get in the way of day to day functioning http://www.ncbi.nlm.nih.gov/books/NBK66039/ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0032735/ Images: various internet sources
  29. 29. Support Various internet sources, SHARE and Robin Cohen
  30. 30. It is a truthuniversallyacknowledged, that a womanin possessionof recurrentovariancancer must bein want of more effectivetreatments. Adapted from Pride and Prejudice by Jane Austin.
  31. 31. Different paths to long-term management
  32. 32. Exciting times! DataInformationKnowledge Source: Hanahan D, Weinberg RA. Hallmarks of cancer: the next generation. Cell. 2011;144:646-674.
  33. 33. Confusing times http://www.gutenberg.org/
  34. 34. Frustrating Times Oxfordjournals.org
  35. 35. Goals and Priorities After we have thought about our goals and priorities, it may be easier to decide what we are willing to do to achieve them. One day Alice came to a fork in the road and saw a Cheshire cat in a tree. “Which road do I take?” she asked. “Where do you want to go?” was his response. “I don’t know,” Alice answered. “Then,” said the cat, “it doesn’t matter.” If you don’t know where you want to go, any road will take you there. http://www.alice-in-wonderland.net/resources/pictures/tulgey-wood-inhabitants/
  36. 36. Potential benefits and potential risks
  37. 37. Empowered Decision Making: Important Tools for Navigation • Current tests and scans • Location, volume • Pathology • Type of tumor • Hereditary mutation status • Genetic testing recommended for all ovarian cancer patients • BRCA • Lynch Syndrome? BROCA Panel? • Other information • Molecular profiling? • Assays? • Communication • Open and honest dialogue • Ask questions; Negotiate • Plan to manage side effects • Be your own advocate
  38. 38. Empowered Decision Making: Clinical Trials • Consider using clinical trials to expand treatment options. • Consider participating in clinical trials sooner. The fewer lines of therapy someone has had, the more trials they can qualify for. • Many novel drugs and targeted therapies are paired with approved drugs in trials. Discuss with your medical team whether it is reasonable to delay using those particular approved drugs to help maintain eligibility down the road. http://www.bhdsyndrome.org/http://www.bhdsyndrome.org/http://www.crwf.com/phase-i-ii-iii-or-iv/
  39. 39. SHARE’s Clinical Trial Matching Service http://www.sharecancersupport.org/share-new/clinicaltrial_1/clinicaltrial/
  40. 40. Empowered Decision Making: Second Opinions or Consultations • Fresh look • More treatment options • Clinical trials • Different approach • Similar patient • Confirmation / Explanation • Specialists • Manage Side Effects • Pathology • More brains thinking about YOU! ► Plan ahead! • Reports • Scans • Access to slides
  41. 41. Choice of Therapy Size & Location Platinum Response Molecular Information Schedule of Drugs Cell Type Patient Preference (Hair, etc.) Residual Side Effects or Symptoms Hereditary Mutation Status Is there a clinical trial option? Is it reasonable? Is it available? How does it fit with how I want to live? Clinical Trial Surgery Radiation Approved Therapy Adapted from GCF Survivor Course at NYU 5/15/10: Management of Recurrent Ovarian Cancer, Matthew A. Powell, MD, Washington University School of Medicine, St. Louis, MO
  42. 42. Staying in the game: Keep Options in Play http://www.vehiclehi.com/
  43. 43. Recap: Strategies • Be informed and be your own advocate! • Incorporate Goals and Priorities • Consider Clinical Trials to expand treatment options • Second Opinions / Consultations • Proactively Manage Side Effects • Chemo Breaks! • Keep Options in Play • Explore Different Ways to Cope • Ask for Support • LiveLoveLaugh
  44. 44. Resources NCCN Patient Guidelines: http://www.nccn.org/patients/guidelines/ovarian/index.html NCI Designated Cancer Centers: http://www.cancer.gov/researchandfunding/extramural/cancercenters NCI’s Translational Research Program: Ovarian Cancer SPORES http://trp.cancer.gov/spores/ovarian.htm Society of Gynecologic Oncology (SGO): Information for patients https://www.sgo.org/patients-caregivers-survivors/ NOCC: Ovarian Cancer Resource Guide for Women with Recurrent Disease http://www.ovarian.org/assets/pdf/NOCC_Recurrent.pdf MSKCC About Herbs https://www.mskcc.org/cancer-care/treatments/symptom-management/integrative-medicine/herbs SHARE Clinical Trial Matching Service through EmergingMed http://www.sharecancersupport.org/share-new/clinicaltrial_1/clinicaltrial/ SHARE: http://www.sharecancersupport.org/share-new/oexplore/ Gilda’s Club NYC: http://gildasclubnyc.org/ CancerCare: http://www.cancercare.org/patients_and_survivors OCNA—Ovarian Cancer National Alliance: http://www.ovariancancer.org/ NOCC—National Ovarian Cancer Coalition: http://www.ovarian.org/ OCRF—Ovarian Cancer Research Fund: http://www.ocrf.org/ The Human Side of Cancer: Living With Hope, Coping With Uncertainty by Jimmie Holland, MD (Chapter Two: The Tyranny of Positive Thinking) Kevin MD Article about Positive Thinking quoting Jimmie Holland: http://www.kevinmd.com/blog/2011/06/positive-thinking-affects-patients-illnesses.html

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