A discussion on the typical diagnostic work-up, including CT scan, tumor markers, colonoscopy, germline, and somatic testing.
Maurie Markman, MD: What are the common diagnostic tests and the role of surgery? We're going to talk about an antineoplastic therapy.
R. Wendel Naumann, MD: Generally, when we see patients with advanced disease and we are planning surgery, we would like to get a CT [computed tomography] scan to see if this patient is a good candidate for either primary surgical debulking or neoadjuvant chemotherapy in the work-up. We like to do tests to exclude colon cancer, tumor markers CA-125 [cancer antigen 125] and CEA [carcinoembryonic antigen] as well—and a colonoscopy when indicated. And then we assess the patient in terms of their ability to tolerate surgery and our ability to remove all the disease at the time of surgery.
Maurie Markman, MD: New world now. In conversations now we begin to ask routinely about germline molecular testing and somatic testing—this is going to be very relevant to the conversation we're going to have about PARP [poly ADP ribose polymerase]. What is the role of germline and somatic testing in your view?
R. Wendel Naumann, MD: This has gotten very complicated with the data that have come out, obviously. We now know up front that we need germline testing and somatic testing to determine whether patients are candidates for PARP, based on the SOLO-1 data. They have about a 70% reduction in recurrence risk at any given point if they go on a PARP if they're BRCA-positive, either germline or somatic. And so I think we probably need that information on every patient up front as part of the initial evaluation.
Michael Birrer, MD, PhD: Can I add in something? I think Wendel covered it very well. Historically, we knew these patients, all of them should essentially get genetic testing about 5 years ago. But we've not been very effective at it. We were in the 30% range for a long time even though SGO [Society of Gynecologic Oncology], NCCN [National Comprehensive Cancer Network], ASCO [American Society of Clinical Oncology] all recommended sequencing. SOLO-1 has actually changed it, and now we're up I think above 50% to 60%. But the key is it doesn't matter what kind of histology [it] is, it doesn't matter the age of the patient, everybody should get sequencing and genetic testing.
R. Wendel Naumann, MD: And to emphasize that point, one of the problems as we adapt to the new world is how to do that, what test to order, what is the most effective way to do that in terms of sequencing. Can we do 1 test? Do we do multiple testing? I think that's less clear, but everybody does need to be tested.
Maurie Markman, MD: What I would add to that is I know a variety of algorithms have been thought about, family history, and it's very clera that you simply just ask questions about family history, and it's not adequate. It just doesn't work, and you're going to miss this, so there's no way around it. Standard care should be to obtain this testing.