Bevacizumab: First-Line Therapy in Ovarian Cancer?

Robert A. Burger, MD; Kenneth D. Swenerton, MD, FRCPC; Maurie Markman, MD

Disclosures

April 19, 2012

In This Article

Who Should Receive Bevacizumab?

Dr. Markman. Thank you, Bob. If you don’t mind, I would like to have you answer several more questions before turning to Ken for his response. On the basis of the GOG-218[1] and ICON 7 trials,[2]which patients should be considered to receive bevacizumab as a routine component of their primary chemotherapy regimen?

Dr. Burger. Level-1 evidence would suggest that patients with advanced epithelial ovarian, primary peritoneal, and fallopian tube cancer -- specifically those with either stage III, incompletely resectable tumors or with stage IV tumors after maximal attempt at surgical cytoreduction -- be considered for treatment with bevacizumab in conjunction with and following standard platinum-taxane chemotherapy.

Dr. Markman. The GOG trial found that patients who only received bevacizumab during chemotherapy did not experience an improvement in PFS. On the basis of this finding, should bevacizumab be delivered only as a maintenance therapy and not during chemotherapy?

Dr. Burger. That is an excellent question, but unfortunately it is impossible to answer without further investigation. The magnitude of benefit from bevacizumab seems to be related to duration of treatment. The answer to this question would require a study directly comparing outcomes between those receiving chemotherapy followed by bevacizumab maintenance vs those receiving chemotherapy combined with bevacizumab followed by bevacizumab maintenance.

Dr. Markman. Should bevacizumab be delivered for a much longer period, perhaps (for example) 3 or 4 years in patients able to tolerate the drug?

Dr. Burger. Both the antiangiogenic mechanism of action of bevacizumab and the supplemental information from the OCEANS trial[3] (in which patients were treated until disease progression rather than for a predefined number of cycles or time period) suggest that, for patients most likely to benefit from bevacizumab, once treatment with bevacizumab is initiated it should be maintained at least until disease progression, barring untoward effects requiring discontinuation.

Dr. Markman. Finally, considering the results of the OCEANS trial,[3] do you have an opinion regarding the strategy of delaying treatment with bevacizumab until the second-line setting?

Dr. Burger. I think that for patients who do not meet the criteria for use of bevacizumab as front- line therapy (as mentioned earlier) and who relapse should be considered for treatment with bevacizumab as part of second-line therapy.

Dr. Markman: Thank you, Bob, for your succinct responses. Ken, could you please comment both on Bob’s interpretation of the 2 first-line bevacizumab studies and his responses to my previously stated questions? I am particularly interested in your interpretation of who -- if anyone -- should receive bevacizumab as a routine component of their primary treatment program. If bevacizumab is administered as first-line therapy, how should it be delivered? Should it be delivered only as maintenance therapy and at what dose and for what duration?

Also, it certainly would be fair for you to bring in the issue of cost, in that the health system in Canada has a very different approach to using this or any new or novel antineoplastic drug on a routine basis. 

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