How To Manage A Recurrence Of Ovarian Cancer

Eighty percent of women with ovarian cancer enter into remission. However, during the next five years, 70 to 80 percent of those women may have a “recurrence,” when the cancer comes back, according to Dr. Beth Karlan, a gynecologic oncologist at the UCLA Medical Center whose skill as a clinician is noted among her colleagues. The probability of recurrence is, without question, daunting, but there are exciting new options for treatment.

What Is Happening During a Recurrence?

To explain what’s happening in your body in the most basic terms, recurrence often occurs because some cancer cells are left behind after treatment, and, over time, they grow larger. Your cancer may have specific features which means these cells just didn’t respond well to treatment.

According to Dr. Karlan, the type of treatment recommended for recurrence can depend on a number of factors:

• The time period within which the cancer recurred
• The kind of chemotherapy the woman underwent in the past
• Side effects that came as a result of past treatments
• The length of time between the last treatment the woman underwent and the recurrence
• The specific mutations and molecular features of your cancer

If a woman’s time in between remission and recurrence is more than six months then the ovarian cancer is categorized as “platinum-sensitive” (that is, responsive to a platinum-based chemotherapy treatment) and that patient will be treated with chemotherapy and another platinum-based drug. However, if the recurrence time happens less than six months into remission, the ovarian cancer is classified as “platinum-resistant.” At that point, women are usually treated with another type of chemotherapy and encouraged to enter into a clinical trial. Alternatively, women might be platinum refractory, which refers to disease that grows while the patient is on chemotherapy and has a particularly poor prognosis.

Options for Recurrence- PARP Inhibitors

There is growing data to support the idea that PARP Inhibitors, the class of drug which inhibits cancer cells from repairing their DNA can benefit a wide swath of women. PARP inhibitors are especially beneficial for women who have genetic testing to discover that they have a mutation called BRCA.

Summary of PARP inhibitors Eligibility For Recurrence 

For women with ovarian cancer who have had a recurrence and responded to platinum-based chemotherapy, Lynparza, Zejula and another PARP inhibitor called Rubraca (rucaparib) are FDA approved for use as a maintenance therapy, regardless of whether a woman has a BRCA mutation or HRD.

For some women who have had prior chemotherapy treatments, Rubraca, Zejula or Lynparza may also be options. These uses are based on factors such as number of prior therapies and BRCA mutation or HRD.

The different PARP inhibitors do have some varying side effects, which women and their doctors need to evaluate carefully. It’s important to ask your doctor if he or she has experience managing the side of effects for the various PARPs. Some of these considerations are explained here.

Other Tools to Fight Ovarian Cancer Recurrence

Oncologists can also use a tactic to determine if there is something called “microsatellite instability” in the tumor, which can indicate whether immunotherapy is an option, according to Karlan. Trying to activate the immune system to fight cancer through one of the approved immunotherapy drugs is not yet proving very effective for ovarian cancer, but there are interesting clinical trials going on which combine immunotherapy with other agents.

Clinical Trials 

In the rounds of treatment after a recurrence, Karlan says that experienced doctors look at clinical trials to see if a woman’s disease has some of the features which might make her a potential candidate for novel agents or combinations.

Participating in a clinical trial can provide benefits while also providing vital information to the entire scientific community about potential future treatments.

Repeated Treatment is Possible

Dr. Karlan explains that oncologists may well treat women whose cancer comes back “three, four five, six, seven or eight times” and often it’s during treatment for their fifth or six recurrence that they might go back into remission.

This repeated treatment is possible as a result of a doctor’s careful analysis of a woman’s prior treatments, the time between treatments, and analysis of their tumors.

Probability of Recurrence

Determining the probability that a woman’s cancer will recur depends on the stage at which they were originally diagnosed. According to most data, when diagnosed, women with stage one ovarian cancer have a 10 percent chance of recurrence, women in stage two have a 30 percent chance of recurrence and women in stage three have a 70 to 90 percent chance of recurrence. When your disease is given a stage four designation, unfortunately there is a 90 to 95 percent chance of recurrence.