Current and future options for sequential
therapy for first and subsequent relapses in
ovarian cancer were discussed in three workshops centered around a number of case studies. The participants included investigator oncologists from the USA, Europe, and Asia. For a
platinum-resistant patient,
topotecan or
pegylated liposomal doxorubicin was considered the treatment of choice at first relapse. Since optimal tolerability with
topotecan is achieved in less heavily pretreated patients, it may be best to use it earlier rather than later in the treatment schedule. For subsequent relapse within 6 months, most clinicians would use liposomal-encapsulated
doxorubicin if the prior treatment had been
topotecan and vice versa. Alternative agents may be considered with the aim of achieving symptom palliation rather than prolongation of survival. For late relapse after optimal debulking and treatment with
carboplatin/
paclitaxel,
retreatment with
carboplatin/
paclitaxel (possibly after further surgery) was considered the best approach in
platinum-sensitive patients. For first relapse after 10 months in a suboptimally debulked patient,
retreatment with
carboplatin/
paclitaxel was also considered a viable option. Alternatively, single-agent
therapy with
paclitaxel,
pegylated liposomal doxorubicin, or
topotecan may be appropriate to prolong the
platinum-free interval. For second relapse, oral
etoposide was felt to be useful. Treatment for subsequent relapses included
gemcitabine,
docetaxel, and agents above not previously utilized.
Topotecan tolerability and convenience may be improved by employing a lower dose, shorter schedule, 21-day continuous infusion or weekly dosing in relapsed/refractory disease. The progression-free interval may be extended by continuing
topotecan until
disease progression in patients with stable disease or by
topotecan consolidation
therapy in treatment responders.