Second-Line Options After First-Line Bevacizumab
Key opinion leaders consider whether frontline bevacizumab will affect second-line therapy options.
Maurie Markman, MD: Does the use of frontline bevacizumab affect second-line therapy options? Wendel?
Wendel Naumann, MD: I think that probably the only way that it affects my decision making is the toxicity of the bevacizumab in terms of renal toxicity and tolerance of the drug. There's good evidence that you're going to get a benefit from bevacizumab in the second-line setting even if you used it in the first-line setting. If you look at GOG-213, the use of bevacizumab was not an exclusion for that trial, so about 10% of those patients received bevacizumab before they went on to the bevacizumab in the platinum-sensitive recurrent setting.
I judge my use of bevacizumab based on the characteristics of the patients. So, when people come in with ascites, or carcinomatosis and no evidence of bowel obstruction, I tend to lean toward bevacizumab, particularly if they've recurred in that 6 to 9 month range where I think that they're going to have less of a chance of responding to chemotherapy. Remember, they have to respond to chemotherapy to get on to a PARP inhibitor, if you're going to get them to a PARP inhibitor. We know that adding BEV [bevacizumab] in the recurrent setting increases the response rate to chemotherapy in the 15% to 20% range.
Michael Birrer, MD, PhD: Are you treating to progression, Wendel?
Wendel Naumann, MD: In the frontline setting or in the recurrent?
Michael Birrer, MD, PhD: Either.
Wendel Naumann, MD: I don't in the frontline setting, based on the data. As you said, the BOOST trial should have read out late 2018. It's not been presented, as you pointed out. I don't know where that data exist or where they will be presented, but we'll have some indication if extending the bevacizumab. I certainly think it will increase the PFS [progression-free survival]. And as you know, it's very difficult in an upfront trial to show a survival benefit, to a statistical phenomenon. Again, my decision in the recurrent setting is independent of my decision in the frontline setting. But I will say most of the people who got bevacizumab in the frontline setting are probably going to not do well because of the way I choose my patients.