Cancer Therapy Advisor also reached out for comment to Stephen Cannistra, MD, professor of medicine at Harvard Medical School and the corresponding author of the paper suggesting bevacizumab be used in the adjuvant and maintenance settings in the ovarian cancer subgroup, but did not receive a response.

“We agree that bevacizumab maintenance should not be indiscriminately used for all patients with optimally debulked stage IIIc disease,” Dr Cannistra and his colleagues wrote in their reply to the authors of the letter published in the same journal.4 “However, (…) we believe that patients with advanced stage IIIc EOC, including those with optimally debulked disease, deserve a discussion of the data and be made an active participant in decision making.”

The idea that adding bevacizumab, or another drug, to a patient’s regimen improves progression-free survival is nothing new, Dr Buckanovich said. “The more drugs you add, [the more] you improve the progression-free survival,” he said. “We have shown this again and again and again in ovarian cancer.” But adding more drugs also increases the burden of toxicity without prolonging overall survival, he said.

“It’d be one thing if we’re talking about adding 3 months of drugs, but we’re talking about adding 2 years of drug, frequent patient appointments, hundreds of thousands of dollars in costs without any evidence that we can make the patient live longer from it,” he said.

Amit Oza, MD, a professor of medicine at the University of Toronto, appeared to agree more with the authors of the original paper than the authors of the letter. “I think that the original authors basically contend that based on progression-free survival, the patient that they discussed in this case would have benefit in terms of delaying progression,” he said. “And I think in that statement, the original authors are right — that there is benefit in that setting.”

“I think that the people who wrote the letter are taking a hard line,” Dr Oza added.

The above debate reflects some of the dilemmas that gynecologists treating ovarian cancer face every day, said Veena John, MD, system head of GYN medical oncology at Northwell Health Cancer Institute in Lake Success, New York. “Even though, as cited by the authors in the article, bevacizumab has been approved in first-line treatment as well as maintenance treatment, this still is not widely embraced by all gyn oncologists,” she said. “The reservation may stem from the toxicity and cost [versus] benefit. As stated in the article, bevacizumab comes with serious side effects, and none of the studies showed an overall survival benefit.”

However, some groups of patients, such as those with advanced disease, suboptimal surgery, or stage IV disease as illustrated in ICON-7, may indeed benefit from bevacizumab as maintenance, Dr John said.

For a patient who comes in for first-line treatment after an R0 resection of stage IIIc ovarian cancer, she said: “I will have a discussion with the patient regarding bevacizumab. And hopefully make a decision together.”

References

  1. Bouberhan S, Shea M, Cannistra SA. Advanced epithelial ovarian cancer: Do more options mean greater benefits? J Clin Oncol. 2019;37(16):1359-1364.
  2. Buckanovich RJ, Rustin G, Uppal S, et al. No role for maintenance bevacizumab for up-front stage IIIc (R0) ovarian cancer. J Clin Oncol. 2019;37(29):2707-2708.
  3. Madariaga A, Rustin GJS, Buckanovich RJ, et al. Wanna get away? Maintenance treatments and chemotherapy holidays in gynecologic cancers. Am Soc Clin Oncol Educ Book. 2019;39:e152-e166.
  4. Bouberhan S, Shea M, Cannistra SA. Reply to R.J. Buckanovich et al. J Clin Oncol. 2019;37(29): 2708-2709.