Decision to be made: 2 more rounds of chemo?

Dr. Goodman,  I have a friend in Maine who is being treated for Stage 3 ovarian cancer. She had a hysterectomy and related illeostomy, and they removed all ovarian tumors they could see . She has just completed 6 rounds of chemo -Taxol and Carboplatin, and while the post-treatment CT scan seemed "ok", her CA125 is 195 after the 6th round.  She's being told that she can do 2 more chemos - keeping on the 3-week schedule, that would mean this week- but has been given little info on what that might mean in terms of greater success, reducing the CA125, or her future options.  The decision is being left up to her, and her doctor is on vacation this week.  My questions are: how common is it to do 8 chemos in this situation, is there any other/better option, and is the CA125 ever wrong - should they recheck it.  She has also had a fever of unknown origin for over a week, is on antibiotics.  Can infection affect the CA125.  Many thanks for your help.

[Annekathryn Goodman, M.D.]

Hi There,
You ask a very important question. CA 125 levels can vary because of many factors - cancer , inflammation and so forth.
But for someone on active therapy for a known ovarian cancer, most of the CA 125 elevation will be from that cancer. So the value can be used to determine how well the cancer is responding to the chemo. I have pasted 2 interesting studies below.
The first one shows that women who have their CA 125 go into the normal range have a longer time in remission. The second study shows that women who finish their chemo course with the CA 125 in the normal range have a better prognosis.

so for your friend, her CA 125 is still elevated after 6 cycles. That is very worrisome that she is not in remission and that her cancer will grow back in the near future. Her doctor has identified that and is suggesting continued therapy. If the CA 125 has been progressively declining on her current chemo, then continuing with the same chemo makes sense. If her CA 125 values have plateaued, she should change to a different drug regimen
best wishes


The timing of normalization of CA-125 levels during primary chemotherapy is predictive of survival in patients with epithelial ovarian cancer.
Rocconi RP, Matthews KS, Kemper MK, Hoskins KE, Huh WK, Straughn JM Jr.
Division of Gynecologic Oncology, Mitchell Cancer Institute, University of South Alabama, Mobile, AL 36604, USA. ***@****

OBJECTIVE: To determine if the timing of normalization of CA-125 levels during primary chemotherapy for epithelial ovarian cancer (EOC) could predict survival. METHODS: Patients who reached a complete clinical response for EOC with primary taxane/platinum-based chemotherapy were eligible. Patient demographics, chemotherapy administration, CA-125 levels, and survival outcomes were abstracted. Progression free survival (PFS), overall survival (OS), and platinum sensitivity (>6 months from chemotherapy completion) were compared to CA-125 levels during primary therapy. RESULTS: 262 patients who achieved a complete clinical response were identified. Patients who achieved normalization of CA-125 by 3rd cycle of chemotherapy were compared to patients who failed to achieve normalization by the 3rd cycle. Patients with early normalization demonstrated improved PFS (19 vs. 6 months; p<0.001), OS (48 vs. 27 months; p<0.001) and platinum sensitivity (78 vs. 22%; p<0.001). This survival advantage was maintained when patients were evaluated by debulking status. Additionally, when stratified by the specific cycle patients' achieved normalization, PFS ranged from 25 months after surgery to 2 months after 6th cycle (p<0.001). OS demonstrated a similar trend from 74 months to 22 months (p<0.001), while platinum sensitivity decreased from 72% to 24% (p<0.001). An average of 3.8 months in PFS and 8.6 months of OS was gained for each one-cycle improvement in CA-125 normalization. CONCLUSION: Earlier normalization of CA-125 levels during primary chemotherapy for EOC predicts improvement in platinum sensitivity, PFS, and OS. This data provides prognostic information that may influence future decisions regarding chemotherapy and potentially earlier enrollment in treatment protocols.
J Gynecol Oncol. 2008 Sep;19(3):169-72

Clinical utility of CA-125 for maintenance therapy in the treatment of advanced stage ovarian carcinoma.
Micha JP, Goldstein BH, Rettenmaier MA, Brown JV 3rd, John CR, Markman M.
Gynecologic Oncology Associates, Hoag Cancer Center, Newport Beach, CA 92663, USA.

Maintenance therapy has been extensively studied to discern any prospective therapeutic advantage in the treatment of advanced stage ovarian carcinoma. The CA-125 assay may have prognostic benefit in determining whether this treatment regimen is appropriate for ovarian carcinoma patients who achieve a complete response to first-line therapy. We retrospectively documented the CA-125 levels of 2 advanced ovarian cancer patient groups who exhibited a clinically defined complete response to their primary induction therapy. Patients were then treated with a paclitaxel-based maintenance therapy regimen. The first group (group A; n = 13 patients) received 3 cycles of single-agent paclitaxel maintenance therapy, and the second group (group B; n = 13 patients) received 12 cycles of single-agent paclitaxel maintenance therapy. The premaintenance therapy CA-125 serum levels ( or =10 U/mL) of the 2 treatment groups were then retrospectively evaluated in an intragroup analysis to discern any relationship with progression-free survival (PFS) and overall survival. There was a statistically significantly relationship between the CA-125 levels (<10 U/mL) premaintenance therapy and PFS. The patients who had the lowest CA-125 levels exhibited the most favorable PFS results. Despite the limited sample size and nonrandomized nature of this study, these results are provocative and suggest that advanced ovarian cancer patients who achieve an excellent response to primary platinum-based chemotherapy with a CA-125 serum level less than 10 U/mL may be more amenable to the benefits of paclitaxel maintenance therapy.
Int J Gynecol Cancer. 2009 Feb;19(2):239-41