To the Editors:
The current coronavirus disease 2019 (COVID-19) pandemic has created challenges for the treatment of patients with cancer. Patients with epithelial ovarian cancer (EOC) represent a group of patients with high utilization of healthcare. These patients are at a high risk of contracting COVID-19 because of the following factors: older age (≥65 years), medical comorbidities, and Eastern Cooperative Oncology Group status ≥2.
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Although the traditional treatment for these patients includes both surgery and chemotherapy, surgery for patients with EOC is currently categorized as semiurgent by the Society of Gynecologic Oncology (SGO) with an acceptable delay of 1–4 weeks.Society of Gynecologic Oncology
Gynecologic oncology considerations during the COVID-19 pandemic.
Gynecologic oncology considerations during the COVID-19 pandemic.
https://www.sgo.org/clinical-practice/management/covid-19-resources-for-health-care-practitioners/gyn-onc-considerations-during-covid-19/
Date: 2020
Date accessed: April 10, 2020
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Furthermore, the SGO has stated that use of neoadjuvant chemotherapy may be effective in delaying surgery and hospitalization during the COVID-19 pandemic.2
Society of Gynecologic Oncology
Gynecologic oncology considerations during the COVID-19 pandemic.
Gynecologic oncology considerations during the COVID-19 pandemic.
https://www.sgo.org/clinical-practice/management/covid-19-resources-for-health-care-practitioners/gyn-onc-considerations-during-covid-19/
Date: 2020
Date accessed: April 10, 2020
Patients with BRCA mutations represent a unique group of patients with EOC because of their exquisite platinum sensitivity and impressive progression-free survival with poly(ADP-ribose) polymerase (PARP) inhibitor maintenance. Here, we report on 2 patients with germline BRCA-mutated EOC for whom a complete clinical response (cCR) was detected by cancer antigen 125 (CA-125) testing and imaging to platinum-based chemotherapy and who were then transitioned directly to olaparib in lieu of interval debulking surgery (IDS). Although these patients were treated before the COVID-19 pandemic, this strategy is even more relevant given the additional complexity of caring for patients with EOC in the context of COVID-19.
Brief clinical and oncologic data of the patients are presented in the Table. In both cases, the patients underwent 3 cycles of chemotherapy followed by repeat imaging with plans for possible IDS. However, both patients had continued unresectable disease despite improved CA-125 expression and therefore underwent additional chemotherapy. Patient B had no evidence of disease on positron emission tomography following a total of 6 cycles of chemotherapy, whereas patient A had continued small residual (<1 cm) peritoneal disease on computed tomography of the abdomen and pelvis and completed 3 more cycles of chemotherapy for a total of 9 cycles. Ultimately, both patients had complete resolution of disease on imaging with normalization of CA-125 expression.
TableBrief medical and oncologic information of patients
| Patient ID | Medical comorbidities | Areas of unresectable disease | Initial CA-125 expression | No. of cycles of chemotherapy | Imaging modality used | Response to imaging at conclusion of chemotherapy | No. of cycles of olaparib | Current disease status |
|---|---|---|---|---|---|---|---|---|
| Patient A | Stroke | Upper abdomen, small bowel mesentery | 5655 | 9 | CT with contrast | cCR | 14 | NED |
| Patient B | — | Extensive lymphadenopathy including supraclavicular and mediastinal involvement | 362 | 6 | PET | cCR | 10 | NED |
CA-125, cancer antigen 125; cCR, complete clinical response; CT, computed tomography; NED, no evidence of disease; PET, positron emission tomography.
Vetter. Chemotherapy followed by PARP inhibition as an alternative to surgery in patients with BRCA-mutated ovarian cancer during COVID-19. Am J Obstet Gynecol 2020.
a Based on examination, imaging, and CA-125 testing.
There is limited experience in which surgery, either in the primary or interval setting, is omitted for patients with EOC. However, our experiences suggest that patients with BRCA mutations and cCR to primary chemotherapy may be candidates who do not require surgery. Although IDS has been shown to be less morbid than primary cytoreductions, there are still inherent surgical risks.
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Because examination, imaging, and CA-125 testing confirmed a cCR in our patients, these risks were believed to outweigh the benefits.In addition, the availability of PARP inhibition offers patients with BRCA mutations a unique opportunity to benefit from maintenance therapy. Both of these patients underwent genetic testing during their primary chemotherapy as is standard at our institution. This allowed for early identification of the BRCA mutations and their candidacy for maintenance olaparib based on the Food and Drug Administration’s approval of olaparib for frontline maintenance in patients with BRCA1/2 mutations. This is based on the results of SOLO-1, which demonstrated a hazard ratio for disease progression or death of 0.30 (95% confidence interval, 0.23–0.41), favoring olaparib in patients with advanced-stage, high-grade EOC with response to primary platinum-based chemotherapy.
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Ultimately, this study presents an alternative management strategy for patients with EOC and BRCA mutations who have cCRs to platinum-based chemotherapy, especially with the excellent outcomes observed in SOLO-1. This strategy may now be even more relevant in the context of the current COVID-19 pandemic because it allowed both patients to avoid inpatient surgery and hospitalization, which in turn would have allowed for reduction in exposure to patients with COVID-19 and conservation of personal protective equipment. In addition, these patients would not have entered the growing queue of patients whose surgeries may have been further delayed because of some hospitals restricting surgeries during the COVID-19 pandemic.
References
- Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China.Lancet Oncol. 2020; 21: 335-337
- Gynecologic oncology considerations during the COVID-19 pandemic.(Available at:)https://www.sgo.org/clinical-practice/management/covid-19-resources-for-health-care-practitioners/gyn-onc-considerations-during-covid-19/Date: 2020Date accessed: April 10, 2020
- Using the National Cancer Database for outcomes research: a review.JAMA Oncol. 2017; 3: 1722-1728
- Phase III randomised clinical trial comparing primary surgery versus neoadjuvant chemotherapy in advanced epithelial ovarian cancer with high tumour load (SCORPION trial): final analysis of peri-operative outcome.Eur J Cancer. 2016; 59: 22-33
- Maintenance olaparib in patients with newly diagnosed advanced ovarian cancer.N Engl J Med. 2018; 379: 2495-2505
Article info
Publication history
Published online: May 23, 2020
Footnotes
L.J.C. was on an Ad Board for AstraZeneca in 2018. The other authors report no conflict of interest.
This communication has been published in the middle of the COVID-19 pandemic and is available via expedited publication to assist patients and healthcare providers.
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© 2020 Elsevier Inc. All rights reserved.
