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Announcer Introduction
You’re listening to Project Oncology on ReachMD, and this episode is sponsored by GSK. Here’s your host, Dr. Charles Turck.

Dr. Turck:  
This is Project Oncology on ReachMD, and I'm Dr. Charles Turck. Joining me to share how we can tailor treatment plans for patients with recurrent ovarian cancer is Dr. Richard Penson, who's a medical oncologist working in gynecologic oncology at Mass General Hospital in Boston. Dr. Penson, thanks for being here today.

Dr. Penson:
You're very welcome. Good to be here.

Dr. Turck:
Well to start us off, Dr. Penson, would you tell us about the disease-related factors you consider when creating treatment plans for patients with recurrent ovarian cancer?

Dr. Penson:
I think of ovarian cancer in four seasons, and I'll often share this language with a patient at the beginning: the hope is cure, then the hope to get back into remission, the hope to buy more time, quantity of life, and eventually, the focus on care and the hope to buy the best quality of life. And so every new patient I meet, especially with recurrent disease when the goals of care are uppermost in their mind, I will have a conversation with them about what care they would want at the end of their lives. And that is helpful because I think it generates candor about engaging honestly, and it identifies the 10 to 15 percent of patients who just feel overwhelmed with some of the tougher challenges of living with a life-threatening illness.

Dr. Turck: 
Now what are some factors you consider related to previous treatments that patients received?

Dr. Penson:  
So the way we think about recurrent ovarian cancer used to be in two buckets: platinum sensitive or potentially platinum-sensitive disease when more than 6 months has elapsed from past platinum-based therapy, and platinum-resistant disease, refractory if progression happens on a treatment. Now we've really changed that, and we think much more about the histologic type of cancer. Clear cells are very different to endometrioid or mucinous tumors, and we are splitting into focus on different subtypes of ovarian cancer. The genotype of disease, which is a huge split, BRCA-mutated disease, highly penetrant genes like RAD51C, HRD – homologous recombination deficiencies – and half of patients will have homologous recombination proficiency, or lack of HRD. But it's also the treatment-free interval and the number of prior lines, almost more than just lumping into platinum-resistant disease. And now with the exciting advent of antibody drug conjugates, immunohistochemically testing for targets like folate receptor alpha has really changed what we're doing, identifying useful targets that impact survival. And the use of those drugs being moved up earlier in people's treatment plan.

Dr. Turck:  
So how does something like patient fitness factor into the treatment plan?

Dr. Penson:  
My normal patter is to say to patients that your job is diet, exercise, and attitude. And within that, how fit a patient is is huge in terms of how they do on treatment. So, you know, eat a healthy diet. Healthy diet is no animal fat, little red meat, and lots of fruit and veggies. The  American Cancer Society says that patients on treatment should exercise an hour 3 times a week or do 10 minutes of vigorous exercise every day. 

And then I normally have a conversation with patients along the lines that a positive mental attitude is really important for your quality of life. But don't be a victim to the sort of tyranny of having  to pursue a fighting spirit. Be real about how you feel. But if you get depressed – and depression, anxiety, and posttraumatic stress disorder affect about 40 percent of our patients with recurrent disease – get treatment, tablet, or talk. It's really depression that sort of ruins everything, the quality of life and your ability to work with your medical team to get the best out of treatment.

Dr. Turck:  
Now you touched a little bit on this before, but I thought we'd zero back in on patient preferences. What other strategies do you use to understand a patient's unique goals and priorities?

Dr. Penson:  
Yeah, I think we have to practice patient-centered care. So there is nobody who can tell us what the patient needs and wants apart from the patient. So find out from the patient what is important to them, and it may be trivial to us that the neuropathy jangles or losing your hair again is a complete horror, but finding out the patient's priorities really is essential. So for example, we’re using paclitaxel; it really does incur hair loss unless you use a scalp-cooling device. So using pegylated liposomal, doxorubicin, or gemcitabine instead with your combination platinum-based therapy really  can transform things; you don't lose your hair a second time around when the goal is to get back into remission and live for years. That  collaboration, I think, when patients know you're on their side against the cancer, you value their priorities, really makes you solidified as a team.

Dr. Turck:  
For those just tuning in, you're listening to Project Oncology on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Dr. Richard Penson about creating personalized treatment plans for patients with recurrent ovarian cancer. 

So, Dr. Penson, now that we have a better understanding of the key factors you consider and how you find out what matters most to your patients, would you tell us how you balance those two priorities?

Dr. Penson:  
So the way we navigate between these two priorities of optimal cancer care and tailored treatment to patients’ priorities is really be clear about not just the goals of therapy, but the utility of it. And so it is a tough but important conversation to talk about what you really buy with treatment. So with the FDA approval of  mervituximab last year as the first and only therapy for platinum-resistant ovarian cancer that impacts overall survival, we're talking about different sets of quality of life priorities. So patients are concerned about blurry vision and a risk of an  asthma-like syndrome in their lungs, keratitis, and pneumonitis. And so they may be new and quite scary toxicities for patients. And we have to have a conversation about the cost to patients, the risk of toxicity, and the potential benefit in terms of buying more time.

Dr. Turck:  
So now taking a global view, what kind of impact can that patient-centered approach to care have on a patient?

Dr. Penson:  
I think there are two key things about patient-centered decision-making in oncology. The first is, it is a collaboration for that moment. One of the things that dogs patients is regrets about wrong decisions. You know, should I have put myself through more trauma? Or why did I put myself through more trauma? The second is when we make a commitment to engage with patients, and it is a bonded collaboration against cancer, it’s a lifelong commitment  together. The investment that you make at that moment really sets a seal of trust for later when patients are more sick, more vulnerable, and need you more than ever before.

Dr. Turck:  
Now before we close, Dr. Penson, are there any final thoughts you'd like to leave with our audience today?

Dr. Penson:  
I think this is an extremely exciting time for being in oncology. We've seen a revolution in targeted therapy really exemplified by the PARP inhibitors. And now we have the exciting advent of antibody drug conjugates with the challenge of how do we really get immunotherapy to impact survival for ovarian cancer patients. And so with some exciting breakthroughs, we are looking to the future for the next set of breakthroughs to impact patients so they have better quality of life for longer.

Dr. Turck:  
Well with those final thoughts in mind, I want to thank my guest, Dr. Richard Penson, for joining me to discuss treatment plans for patients with recurrent ovarian cancer. Dr. Penson, it was great having you on the program.

Dr. Penson:  
Great to be here.

Announcer Close
This episode of Project Oncology was sponsored by GSK. To access this and other episodes in this series, visit ReachMD.com/ProjectOncology, where you can Be Part of the Knowledge. Thanks for listening!