New avenues are opening up for treatment of gynaecological cancer, Professor Gunnar Kristensen of Oslo University Hospital explains to Open Access Government
Surgery remains an important step in the treatment of ovarian cancer. Two earlier randomised studies revealed the same survival rates for patients who had surgery as the first step of treatment, as for patients who received three courses of chemotherapy before surgery.
The primary goal of surgery is to remove all visible tumours. Unfortunately, the main group of patients in the two former studies did not obtain this goal. In recent years we have seen considerable improvements in pre- and post-operative care, as well as in surgical skills. A new randomised study is now starting to test whether the old findings still hold. In the new study, the demands on surgical skill are high in order to achieve the maximal benefit from surgery.
For ovarian cancer, the traditional point of view has been that it originates from the epithelial surface of the ovaries. In recent years it has become evident that the site of origin often is the fimbrial end of the fallopian tubes. This may have considerable importance for preventative measures; patients with a high risk of developing ovarian cancer could potentially have their fallopian tubes removed after bearing children (if they wish) and spare the ovaries until menopause.
The most important recent finding
For medical treatment of gynaecological cancer, the most important recent finding is from a phase 3 study on maintenance treatment with niraparib in patients with a late relapse of ovarian cancer. Niraparib is a PARP inhibitor, and it has been known for a long time that maintenance treatment with olaparib (another PARP inhibitor) after successful chemotherapy for relapse of ovarian cancer considerably prolongs the time to next relapse in patients with a BRCA mutation.
In the niraparib study, the time to next relapse was substantially prolonged for these patients, but also considerably prolonged for patients without such a mutation. Other PARP inhibitors have also shown promising results. We are awaiting a decision from the European Medicines Agency (EMA) to see whether niraparib will be allowed to be used for patients without a BRCA mutation. The results from the niraparib study indicate a possible use of PARP inhibitors for other patient groups, not just ovarian cancer patients with BRCA mutations.
Immunotherapy for gynaecological cancer
Immunotherapy has gained much interest, especially treatment with immune checkpoint inhibitors. Response rates for ovarian cancer are around 20% with stabilisation of the disease at about 40-50%. It seems that this kind of treatment has the potential to improve long term survival, which is very important. The testing of checkpoint inhibitors began in patients whose tumours did not respond to chemotherapy any longer. After having established the value of this kind of treatment, new studies will test this at an earlier time in the treatment. The value of treatment with immune checkpoint inhibitors is also being tested in other types of gynaecological cancer.
Low grade serous ovarian cancers are relatively indolent. At the time of diagnosis they are often restricted to one ovary and can be managed by surgery alone. For advanced cases it has been shown that maintenance with oestrogen blocking therapy can prolong survival substantially.
Dr Gunnar Kristensen
Professor, Consultant, PhD
Tel: +47 22 935 690
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