Maintenance Chemo

[OVCIndia]

My mom completed her 6th cycle of Carbo/Taxol yesterday. She underwent Neoadjuvant chemo for 3 cycles then had her surgery.  She was optimally debulked with no macroscopic disease left behind.  She then completed the remaining 3 cycles of Carbo/Taxol.  Her CA125 prior to the start of her 6th cycle was 17.  We are now in the process of finalizing the best approach for the remaining treatment.

Due to the extensiveness of her surgery she was not given any chemo through her IP port.  This was reserved for her maintenance.  

A couple of months back her case was discussed with Dr Maurie Markman and was decided that she be put on 3 cycles of IP Cisplatin after the completion of her 6 IV cycles. Yesterday we spoke with Dr Deborah Armstrong and she suggested 16 weekly IP cycles of Taxol.

Her CA125 is a very good marker for her.

At diagnosis 4900
After 2 cycles 1700 (Via IV)
After 3d cycle 700  (Via IV)
After surgery and before 4th cycle 4.8
(Extensive debulking surgery included complete hysterectomy, removal of Omnetum, left and right diaphragm striping, Removal of Inra-aortacaval and para-aortic lymph nodes, removal of rectal sheath due to which had to reconstruct abdomen using a mesh, removal of Appendix)
After 4th cycle 29 (Via IV)
After 5th cycle 17 (Via IV)
After 6th cycle (Via IV)

1>  What is your opinion on these two maintenance regimes ?

2>  Her oncologist says that the first 3 chemos she was given was to shring her tumor.  He considers that her actual
      treatment has begun after surgery which is why he is pusing for 3 more IP treatments to make it a total of 6 after
      surgery?  Would you agree with this statement

3>  Since she developed a tumor at Ascites drain site they had to remove her rectus sheath to acheive complete
      cytoreduction.  Due to this they had to reconstruct her abdomen using a proline mesh.  Does this interfear with IP
      treatments?

[Annekathryn Goodman, M.D.]

Hi There,
Your mother has had very comprehensive surgery and very good chemotherapy. Dr Markman and Armstrong are leaders in our field. Their opinions must be deeply respected.
I would say that the doctor who can make the best assessment of what is safe and reasonable for your mother is the oncologist who is currently taking care of her. That doctor knows her exam, how her response to chemo has been, what side effects she has had.

Theoretically, giving chemotherapy directly into the abdomen seems to improve the duration of time before the cancer comes back. That is called the disease free interval (DFI). The studies that have looked at DFI are only in women who have had primary cytoreduction surgery no less than 1 cm residual cancer after surgery , no bowel resection. There is no data on using intraperitoneal chemotherapy as maintenance therapy. It is very toxic. In Dr Armstrong's study, 60 % of women were unable to completer the prescribed course of therapy because of toxicity.

It may be that IP chemo is reasonable for your mother but so far we do not have the data to support that approach. But we do have the good opinions of these excellent leaders in the field of gyn oncology.

Your mother is definitely at risk for recurrence. I would agree that pushing on with a good 6 cycles postop makes sense to me. However if your mother is having trouble with her blood counts or is developing  a significant neuropathy, I would consider stopping sooner.

As far as IP chemo -  I would worry about the development of tumor along to port site if she developed a nodule from a paracentesis. There is also a higher risk of abdominal wall infection with a mesh.
best wishes

[Annekathryn Goodman, M.D.]

Hi There

I would suggest not checking CA 125 levels until she is completely finished with her IP chemotherapy. Any irritation of the lining of the abdomen will cause an elevation in this test.
I would wait a good 2 to 3 months after completing this plan before checking.

Please see my other response today on OvaSure
best wishes

[OVCIndia]

Dr Goodman,

Thank you for your response.  My mother has completed her 2d cycle of IP cisplatin consolidation last Saturday.  She has maintained a good performance through her treatments.  Her oncologist said he will give a minimum of 3 cycles and evaluate what needs to be done further.  

My questions for you are

1> How many weeks after her last IP treatment is it reasonable to do a CA125 test since her oncologist has also asked us not to monitor her CA125 during these IP
consolidation treatments.

2> Before the start of her consolidation IP treatments she had an abdominal ultrasound which came out normal and a CA 125 test was 14 and has remained in the normal range right after her interval debulking.  Her oncologist has asked to monitor her using ultrasound and CA 125 tests because she was debulked to the extent of no gross residual disease and thinks a PET/CT will not show anything at this point.  Is CA 125 and ultrasound enough to say that one is in remission?   She had a PET/CT at diagnosis and one before her debulking surgery.

3> I have read reports that LabCorp has launched a new diagnostic test OvaSure that detects Ovarian Cancer at a very early stage to a 95 % accuracy.  Can this test be used to monitor microscopic activity after completion of first line treatment?

Thanks again
OVCIndia

[OVCIndia]

Dr Goodman,

An update to my prior post.  My mother today went to her Gyn-Onc for a checkup 2 weeks post her 6th cycle of IV Carbo/Taxol.  On examining her things looked fine.  He could feel a little fullness so ordered her for an ultrasound.  The ultrasound came back normal.   She is due for her CA125 test next week.  He asked not to go in for a CT/PET for now because last time it did not show lot of activity but on opening her up they found extensive spread.  He said that her CA125 is a good marker for her so well just monitor that and occasionally do an ultrasound

We are back at the same dilemma as to the next steps.  The Gyn-Onc said that they do not have a lot of experience on Maintenance IP treatments and in India there are only a handful of people who have even got IP in their first line.

1>  What is your opinion on the two maintenance regimes recommended by Dr Maurie Markman and Dr Deborah Armstrong on my prior post?

2>  Her Medical oncologist says that the first 3 chemo’s she was given was to shrink her tumor.  He considers that her actual treatment has begun after surgery which is why he is pushing for 3 more treatments to make it a total of 6 after surgery?  For now he is inclined towards 3 IP treatments by giving Day 1 IP Cisplatin and Day 8 IP Taxol since she has already had 6 treatments with IV taxol he does not want to give this on Day 1.    Would you agree with treatment plan?

3>  Since she developed a tumor at Ascites drain site they had to remove her rectus sheath during surgery to achieve complete cytoreduction.  Due to this they had to reconstruct her abdomen using a proline mesh.  Does this interfere with IP treatments if they go with this approach?


Thanks
OVCIndia