The Role of PARP Inhibitors in the Management of Ovarian Cancer - Episode 9

Practice Pearl 2: Improving Outcomes With PARPi Therapy in Ovarian Cancer

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Bradley J. Monk, MD, FACS, FACOG, and Jennifer MacDonald, PharmD, BCOP, share insight on improving outcomes and optimizing therapy with PARP inhibitors in the frontline maintenance setting for ovarian cancer.

Jennifer MacDonald, PharmD, BCOP: Dr Monk, go ahead, and then I’ll ask you a question.

Bradley J. Monk, MD, FACS, FACOG: There’s this perception out there that anticancer therapy is supposed to make you sick. And so what I say is, “I can’t fix anything unless I know about it. If you’re at home and you have an adverse reaction or adverse effect, I’ve got to know about it. It’s my job. I’ve got 2 jobs. You’ve got to live longer and better. If you’re living longer but not better, then that’s on me to fix. Two things can hurt you: the medication and your cancer. I want my cake and to eat it, too. I want you to be cancer-free and asymptomatic from the medication. And we can generally do that.”

This is the message, and you see that from the results of PRIMA. Recently we showed that with appropriate dose modifications, the time, and whether its toxicity from the medication was short. If you took the medication, it delayed the time from toxicity to cancer longer. If you subtracted those 2 out, the time from toxicity of the medication and the time from toxicity of the tumor, there was an advantage in the quality of the life. The metrics that we’re using to evaluate the patient experience are pretty sophisticated and it’s exciting to see these endpoints evolve.

Jennifer MacDonald, PharmD, BCOP: I have that conversation a lot with patients where I say, “We really want to maximize your quality of life. The point of doing this is to keep you alive to live a meaningful, joyful, great life. The point of this isn’t for you to be miserable.” Sometimes we have conversations when someone is like, “I can’t do this, I can’t go on with this.” Let’s dose adjust. It may not meet things like grade of toxicity according to the PI [prescribing information], but some of those are subjective. When you get into fatigue and stuff, it’s based off of ADLs [activities of daily living] and other things that the patients can do and how they’re tolerating it. You may think it’s a grade 2, but the patient thinks it’s a grade 3, so you dose adjust.

That’s something important that we paint for patients a lot. There’s a lot of room to dose adjust. By and large, the data has shown that regardless of dose reduction, if it’s needed for a patient, the benefit is still there for your therapy. We’d rather keep you on it and dose adjust as opposed to you stopping it. But you’ve got to give us a chance to tell us these things and at least try.

Bradley J. Monk, MD, FACS, FACOG: It’s a good example. Last week, I was seeing this patient on a clinical trial, and my clinical research coordinator said, “This patient needs a dose reduction, but it looks like it’s only a grade 2, and dose reductions aren’t allowed until grade 3.” I said, “You just answered the question. It’s a grade 3 because she needs a dose reduction, just like you said.”

Jennifer MacDonald, PharmD, BCOP: That’s important for patients. I know a lot of our women are in support groups and they talk through things. Sometimes even talking to other women in these support groups can be helpful because they’re like, “I’m on it. I’ve been on it for a year and I’m doing excellent. I had some issues in the beginning. I had some struggles for the first month or 2, we had to tweak the dose.” But sometimes that’s helpful for me, too, and I’ll mention, “There are these support groups out there if you want to talk to women or things like that.” Sometimes that can backfire on you, too, so I won’t say it’s always a great thing. That quality of life piece is so important to talk to patients about and to let them know that you care. “I care about your quality of life. I don’t want to just do this and make you miserable in the process.”

Does anyone have any other comments about managing the first couple of months of therapy for patients? It looks like we’ve covered it.

Bradley J. Monk, MD, FACS, FACOG: Sarah, you said for one PARP inhibitor, niraparib, you do weekly blood counts. We do weekly blood counts for every patient.

Sarah Hayward, PharmD, BCOP: We actually do that, too.

Jennifer MacDonald, PharmD, BCOP: We do every 2 weeks for olaparib and rucaparib but weekly for niraparib.

Sarah Hayward, PharmD, BCOP: We decided to do that to have less confusion across the board for our nursing staff.

Bradley J. Monk, MD, FACS, FACOG: Same here. We’re not smart enough to have 2 ways to do things.

Sarah Hayward, PharmD, BCOP: It’s so people didn’t have to remember this for this, and this for this, and this for this. It’s just easier to do it, so that’s what we tell patients.

Transcript Edited for Clarity