key: cord-0939010-phwq8rsf
authors: Vetter, Monica Hagan; Smrz, Stacy A.; Copeland, Larry J.; Cohn, David E.
title: Chemotherapy directly followed by PARP inhibition as an alternative to surgery in patients with BRCA- mutated ovarian cancer – a potential management strategy in the era of COVID-19
date: 2020-05-23
journal: Am J Obstet Gynecol
DOI: 10.1016/j.ajog.2020.05.037
sha: cd2056f3bd320f1f1ce6b890405c78d639e084a5
doc_id: 939010
cord_uid: phwq8rsf

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The current COVID-19 pandemic has created challenges for the treatment of cancer patients.

Patients with epithelial ovarian cancer (EOC) represent a group of patients with high utilization 48 of healthcare. These patients are high-risk for COVID-19 because of their older age (>65 years 49 old), medical co-morbidities, and ECOG status > 2. 1,2 While the traditional treatment for these 50 patients includes both surgery and chemotherapy, surgery for patients with EOC is currently 51 categorized as semi-urgent by the Society of Gynecologic Oncology (SGO) with an acceptable 52 delay of 1-4 weeks. 3 Furthermore, SGO has stated that use of neoadjuvant chemotherapy 53

(NACT) may be effective in delaying surgery and hospitalization during the COVID-19 54

pandemic. 2 55 56

Patients with BRCA mutations represent a unique group of EOC patients due to their 57 exquisite platinum-sensitivity and impressive progression-free survival with PARP inhibitor 58

maintenance. Here, we report on two patients with germline BRCA-mutated EOC who had a 59

complete clinical response by CA-125 and imaging (cCR) to platinum-based chemotherapy and 60

were then transitioned directly to olaparib in lieu of interval debulking surgery (IDS). Though 61 these patients were treated prior to the COVID-19 pandemic, this strategy is even more relevant 62

given the additional complexity of caring for patients with EOC in the context of COVID-19. 63 64 Table 1 presents the brief clinical and oncologic data for the patients. In both cases, the 65 patients underwent 3 cycles of chemotherapy followed by repeat imaging with plans for possible 66 IDS. However, both patients had continued unresectable disease despite improved CA-125 and 67 therefore underwent additional chemotherapy. While patient B had no evidence of disease on 68

PET following a total of 6 cycles, patient A had continued small residual (<1cm) peritoneal 69 disease on CT abdomen/pelvis so completed 3 more cycles for a total of 9. Ultimately, both 70 patients had complete resolution of disease on imaging with normalization of CA-125.

There is limited experience in which surgery, either in the primary or interval setting, is 73 omitted for patients with EOC. However, our experiences suggest that patients with BRCA 74 mutations and cCR to primary chemotherapy may be candidates to avoid surgery. While IDS has 75 been shown to be less morbid than primary cytoreductions, there are still inherent surgical risks. 4 76

As our patients had cCR by exam, imaging, and CA-125, these risks were felt to outweigh the 77 benefits. 78

Additionally, the availability of PARP inhibition offers patients with BRCA mutations a 79 unique opportunity to benefit from maintenance therapy. Both of these patients underwent 80

genetic testing during their primary chemotherapy as is standard at our institution. This allowed 81

for early identification of the BRCA mutations and their candidacy for maintenance olaparib 82

based on the FDA-approval of olaparib for frontline maintenance in patients with BRCA1/2 83 mutations. This is based on the results of SOLO-1 which demonstrated a hazard ratio for disease 84 progression or death of 0.30 (95% CI, 0.23-0.41) favoring olaparib in patients with advanced 85 stage high-grade EOC with response to primary platinum-based chemotherapy. 5 86 87

Ultimately, this report presents an alternative management strategy for patients with EOC 88

and BRCA mutations who have complete clinical responses to platinum-based chemotherapy, 89 especially with the excellent outcomes seen in SOLO-1. This strategy may now be even more 90

relevant considering the COVID-19 pandemic as it allowed both patients to avoid inpatient 91 

Cancer patients in SARS-CoV-2 infection: a nationwide 98 analysis in China

Gyn Onc Considerations During COVID-19 | SGO

Using the National Cancer Database for Outcomes 104 Research: A Review

Phase III randomised clinical trial comparing 107 primary surgery versus neoadjuvant chemotherapy in advanced epithelial ovarian cancer 108 with high tumour load (SCORPION trial): Final analysis of peri-operative outcome

Maintenance olaparib in patients with newly 111 diagnosed advanced ovarian cancer