What is the preferred second line agent for a woman with metastatic vulvar cancer who has progressed on carboplatin/paclitaxel?

There is not one preferred second line agent for women with metastatic vulvar cancer who have progressed on carboplatin/paclitaxel. My preference is to put those patients on clinical trial, if possible. Next generation sequencing of the tumor could guide placement into a trial (such as MATCH or TAPUR). If no trial is available, decisions about treatment should be made based on the patient's performance status, prognosis, and wishes. Best supportive care is always a reasonable option, and single agent chemotherapies (such as would be used for metastatic cervical cancer) could be tried for palliation.

We generally extrapolate treatment of vulvar carcinoma from data on cervical cancer as both are lower genital tract HPV-associated cancers. Vulvar cancer is rare enough that randomized trials and even single arm phase II trials have not typically been done. Thus, I usually add bevacizumab to initial chemotherapy given the survival advantage seen with addition of bev to initial chemotherapy for cervical cancer. For recurrent disease, there is a lot of interest in immune checkpoint inhibitor therapy given the foreign antigen, HPV, in most of these cancers. Data from CheckMate 358 using single agent nivolumab for viral associated tumors was presented at ASCO 2017. There were 18 cervical cancer and 5 vulvar/vaginal cancers. ORR was 20.8% but al...