NCCN Issues New, Revised Guidelines for the Treatment of Patients With Ovarian Cancer

By Cameron Kelsall, /alert Contributor
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The National Comprehensive Cancer Network (NCCN) issued new guideline recommendations for the treatment of ovarian cancer, in some cases significantly revising its former directives.

Among its new recommendations was a directive that all patients should undergo genetic risk evaluation, including germline and somatic mutation testing, if they have not already done so. “Germline and/or somatic BRCA1/2 status informs maintenance therapy,” the guideline authors wrote. “In the absence of a BRCA1/2 mutation, homologous recombination deficiency status may provide information on the magnitude of benefit of PARP inhibitor therapy.”

The guideline authors significantly revised recommendations for patients with newly diagnosed ovarian cancer following a recent surgical procedure, with primary treatment recommendations based on the extent of residual disease (no evidence of residual disease on workup, evidence of residual disease on workup, or evidence of malignant germ cell or sex cord-stromal tumors).

The section on recommended maintenance therapies contained several notable revisions. The guideline authors endorsed the use of PARP inhibitor niraparib as a maintenance option for patients with a confirmed complete or partial response whose disease is BRCA1/2 wild-type or unknown, with no previous bevacizumab exposure.

A category 1 recommendation of niraparib was issued for patients with a germline or somatic BRCA1/2 mutation and no bevacizumab exposure, and a category 2A recommendation was issued for patients harboring BRCA1/2 mutations who were treated with bevacizumab during primary therapy. 

The panel further endorsed olaparib as a category 1 maintenance option for patients with a germline or somatic BRCA1/2 mutation who did not receive bevacizumab during primary therapy. Combined bevacizumab and olaparib maintenance was endorsed as a category 2A option for patients in complete or partial response who were treated with bevacizumab during primary therapy.

Postremission bevacizumab was removed as a maintenance option for patients with stable disease following primary therapy with a bevacizumab-containing regimen.

An overall recommendation was made to reclassify “less common ovarian histopathologies” as “less common ovarian cancers.” In the section concerning this constellation of diseases, several new treatment recommendations were issued.

“Due to emerging therapeutics for less common ovarian cancers, there is value in identifying potential pathways for rare cancers, and it may be useful for clinical trial recruitment,” the authors wrote. “Tumor molecular testing can be considered, if not previously done, as it may help guide treatment.”

For patients with carcinosarcoma of the ovary, intravenous (IV) paclitaxel 175/carboplatin was endorsed as the preferred adjuvant treatment strategy. For patients with stage II-IV clear cell or mucinous carcinoma of the ovary, systemic therapy was recommended as adjuvant treatment.

The panel modified recommendations for patients with ovarian borderline epithelial tumors and invasive implants following complete surgical resection. Recommendations are now divided based on serous carcinoma grade (low-grade vs. high-grade). Recommendations were further restructured for patients with incomplete surgical resection, based on the degree of suspected residual disease.

According to the principles of systemic chemotherapy, the guideline recommended that patients with ovarian, fallopian tube or peritoneal cancer should be encouraged to enroll in clinical trials “during all aspects of their diagnosis and treatment.” Chemotherapy-eligible patients should be advised of all treatment avenues available to them, including IV chemotherapy, intraperitoneal (IP) chemotherapy and clinical trials. 

Further, adequate organ function and performance status requirements should be met before the initiation of chemotherapy.

The guideline updated preferred therapy regimens for malignant germ cell tumors (primary, belomycin, etoposide and cisplatin; recurrent, high-dose chemotherapy/paclitaxel, ifosfamide and cisplatin) and malignant sex cord-stromal tumors (primary and recurrent, paclitaxel/carboplatin).

IV or IP paclitaxel/cisplatin is no longer considered an option for patients with low-grade serous carcinoma, grade 1 endometrioid carcinoma, and stage II-IV mucinous carcinoma of the ovary.

Scalp cooling was recommended to reduce the incidence of alopecia among patients receiving chemotherapeutics agents associated with a high risk for the adverse event.

 

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