Do you alter treatment in high grade serous ovarian cancer patients receiving neoadjuvant chemotherapy with stable disease after 3 cycles?

This is always a challenging clinical situation, as the intent of neoadjuvant chemotherapy is to reduce disease burden sufficiently to enable cytoreduction to microscopic residual disease. If disease remains stable despite administration of neoadjuvant therapy, it often denotes a biologically aggressive cancer phenotype. In this setting, I treat with an additional cycle of neoadjuvant chemotherapy and re-assess the patient’s medical status and disease burden: 1) if she is medically fit and there is a reasonable likelihood of achieving optimal cytoreduction with residual disease <1cms, then I recommend surgery and consider continuing chemotherapy post operatively with a platinum containing doublet; 2) if the surgical morbidity is high due to co-existing medical problems and/or likelihood of optimal cytoreduction is low, I counsel against interval cytoreduction and consider continuing with chemotherapy with a platinum containing doublet, while substituting Paclitaxel with an alternative drug such as Gemcitabine. If at any point there is evidence of progression of disease on carboplatin-based regimens, I encourage enrollment in clinical trials for platinum resistant disease if and when possible. I also routinely incorporate molecular profiling of tumors into care of patients.