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COVID-19 and ovarian cancer: Exploring alternatives to intravenous (IV) therapies

2020; Elsevier BV; Volume: 158; Issue: 1 Linguagem: Inglês

10.1016/j.ygyno.2020.04.703

1095-6859

Bradley J. Monk, Robert L. Coleman, Kathleen N. Moore, Thomas J. Herzog, Angeles Alvarez Secord, Ursula A. Matulonis, Brian M. Slomovitz, Saketh R. Guntupalli, David M. O’Malley,

COVID-19 Impact on Reproduction

•The pandemic COVID-19 requires alternative methods and thinking to keep healthcare professionals and patients safe.•In COVID-19 hot spots, oral therapies may be viable alternatives to intravenous therapies for treatment of ovarian cancer.•Minimizing patient visits to hospitals and cancer clinics may help mitigate the spread of SARS-CoV-2. On 11 March 2020, the World Health Organization (WHO) declared the outbreak of the coronavirus SARS-CoV-2 and its associated disease COVID-19 a pandemic [[1]World Health Organization https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020Date accessed: March 22, 2020Google Scholar]. The need to contain and mitigate transmission of SARS-CoV-2 to prevent surges of patients that may overwhelm healthcare systems has led to unprecedented challenges for health care professionals (HCPs) around the world, including managing the use and distribution of healthcare resources. In March 2020, ASCO created a COVID-19 resource center that contains evidence-based, up-to-date information gathered from the medical literature (PubMed), Centers for Disease Control and Prevention (CDC), WHO, Infectious Diseases Society of America (IDSA), clinicians, and infectious disease experts [[2]American Society for Clinical Oncology https://www.asco.org/asco-coronavirus-information/care-individuals-cancer-during-covid-19Date accessed: March 22, 2020Google Scholar]. The WHO-China Joint Mission on Coronavirus Disease published a report indicating that the case fatality rate for COVID-19 patients with cancer as a comorbid condition was 7.6% vs. a case fatality rate of 3.8% in the entire COVID-19 population [[3]World Health Organization https://www.who.int/docs/default-source/coronaviruse/who-china-joint-mission-on-covid-19---final-report-1100hr-28feb2020-11mar-update.pdf?sfvrsn=1a13fda0_2&download=trueDate accessed: March 22, 2020Google Scholar]. In addition, the case fatality rate was 1.4% in COVID-19 patients with no comorbid conditions. Yu et al. found that cancer patients from Wuhan, China had a higher risk of SARS-CoV-2 infection compared with the general community and that hospital admissions and recurrent hospital visits were potential risk factors for infection [[4]Yu J. Ouyang W. Chua M.L.K. et al.SARS-CoV-2 transmission in patients with cancer at a tertiary care hospital in Wuhan, China.JAMA Oncol. March 25, 2020; (Epub ahead of print)https://doi.org/10.1001/jamaoncol.2020.0980Crossref Scopus (813) Google Scholar]. Given these emerging data, it is prudent to reduce visits to the clinic whenever possible to minimize SARS-CoV-2 exposure and risk of transmission, especially in immunocompromised cancer patients. One way to reduce clinic visits is to use oral therapies, especially if there are viable alternatives to IV therapies in the desired setting. Patients who receive IV treatment need to visit a hospital or infusion clinic, which may put further pressure on oncology centers that are being converted to temporary COVID-19 units to help manage outbreaks in the regions they serve. If an oral agent is taken at home, this may help foster an environment that will keep the patient, her caregivers, and her medical team safe by minimizing the need for in-person clinic visits. HCPs will need to assess the benefit-risk profile of each therapy and its mode of administration against other factors, including the patient's goals of care, comorbidities, financial considerations, ability of available nursing services to help manage toxicities, the need to obtain outside laboratory values, susceptibility for developing severe symptoms, and the patient's risk of dying from COVID-19 and/or cancer. Prophylactic use of supportive care (e.g., myeloid growth factor to manage febrile neutropenia) may also help minimize return visits to the clinic. In the setting of ovarian cancer, there are several classes of oral agents that can potentially serve as alternatives to IV therapies, including cytotoxic chemotherapy, inhibitors of poly(ADP-ribose) polymerase (PARP), targeted agents, and hormonal therapies [[5]National Comprehensive Cancer Network Ovarian Cancer (Version 1.2020).https://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdfDate accessed: March 22, 2020Google Scholar]. Eight randomized placebo-controlled trials of PARP inhibitors have been reported, all with improved progression-free survival associated with use as maintenance therapy (primary endpoint hazard ratios, 0.18–0.68) in first line and platinum-sensitive recurrent ovarian cancer [[6]Walsh C.S. Latest clinical evidence of maintenance therapy in ovarian cancer.Curr. Opin. Obstet. Gynecol. 2020; 32: 15-21Crossref PubMed Scopus (23) Google Scholar]. In addition, one randomized phase 3 study demonstrated that a PARP inhibitor had improved efficacy vs. IV chemotherapy in women with germline BRCA1/2-associated relapsed ovarian cancer [[7]Penson R.T. Valencia R.V. Cibula D. et al.Olaparib versus nonplatinum chemotherapy in patients with platinum-sensitive relapsed ovarian cancer and a germline BRCA1/2 mutation (SOLO3): a randomized phase III trial.J. Clin. Oncol. 2020; 38: 1164-1174Crossref PubMed Scopus (183) Google Scholar], suggesting that PARP inhibitors are reasonable alternatives to IV chemotherapy in the treatment setting. During this pandemic, if a patient has persistent disease after receiving 4–6 cycles of platinum-based chemotherapy, she may be an appropriate candidate for maintenance therapy with an oral PARP inhibitor. If active therapies are not used in the maintenance setting, watchful waiting can lead to rapid recurrence and a shorter time to subsequent therapy, which may place more demands on healthcare systems, especially if IV infusions are required. In the treatment setting, holding therapy to reduce SARS-CoV-2 exposure may not be a viable option because of concern that the patient's cancer will progress more rapidly. We believe the principles outlined above may serve as appropriate alternatives for treatment of other solid tumors during this pandemic. As noted in the COVID-19 resource center, there is no direct evidence to support changing or withholding chemotherapy or immunotherapy in patients with cancer. Nevertheless, a brief treatment holiday and/or switching from IV to oral therapies may be viable options for some patients. Within the global healthcare community, the time for action is now: let's use logic and all available therapies—especially if there are viable alternatives to IV therapies that are indicated for use in the desired setting—to keep our patients out of the clinic for nonessential, routine visits. Conserving healthcare resources and minimizing the number of times a patient needs to visit an inpatient or outpatient clinic is a simple, yet powerful strategy to help slow the spread of SARS-CoV-2. Dr. Bradley J. Monk wrote the first draft of this editorial and approved the final draft for submission. Dr. Monk's coauthors (Drs. Robert L. Coleman, Kathleen N. Moore, Thomas J. Herzog, Angeles Alvarez Secord, Ursula A. Matulonis, Brian M. Slomovitz, Saketh R. Guntupalli, and David M. O'Malley) contributed equally to this work and approved the final draft for submission. Dr. Bradley J. Monk reports personal fees from AbbVie, personal fees from Advaxis, personal fees from Agenus, personal fees from Amgen, personal fees from Aravive, personal fees from AstraZeneca, personal fees from Asymmetric Therapeutics, personal fees from Boston Biomedical, personal fees from ChemoCare, personal fees from ChemoID, personal fees from Clovis Oncology, personal fees from Easai, personal fees from Geistlich, personal fees from Genmab/Seattle Genetics, personal fees from GOG Foundation, personal fees from ImmunoGen, personal fees from Immunomedics, personal fees from Incyte, personal fees from Janssen/Johnson & Johnson, personal fees from Laekna Health Care, personal fees from Mateon (formally Oxigene), personal fees from Merck, personal fees from Mersana, personal fees from Myriad, personal fees from Nucana, personal fees from Oncomed, personal fees from Oncoquest, personal fees from Oncosec, personal fees from Perthera, personal fees from Pfizer, personal fees from Precision Oncology, personal fees from Puma, personal fees from Regeneron, personal fees from Roche/Genentech, personal fees from Samumed, personal fees from Takeda, personal fees from Tesaro/GSK, personal fees from VBL, personal fees from Vigeo, personal fees from Iovance, personal fees from Vavotar Life Science, personal fees from Senti Bio, personal fees from Akesio Bio, personal fees from Dicepheria, personal fees from Tarveda, outside the submitted work. Dr. Robert L. Coleman reports other from US Oncology Research, during the conduct of the study; grants and personal fees from AstraZeneca, grants from Merck, personal fees from Tesaro, personal fees from Medivation, grants and personal fees from Clovis Oncology, personal fees from Gamamab, grants and personal fees from Genmab, grants and personal fees from Roche/Genentech, grants and personal fees from Janssen, personal fees from Agenus, personal fees from Regeneron, personal fees from OncoQuest, outside the submitted work. Dr. Thomas J, Herzog reports personal fees from Johnson & Johnson, personal fees from AstraZeneca, Caris, Clovis Oncology, Roche, and Tesaro. Dr. Kathleen Moore reports personal fees and other from Astra Zeneca, grants, personal fees and other from Genentech/Roche, grants, personal fees and other from Immunogen, grants, personal fees and other from Clovis Oncology, grants, personal fees and other from Tesaro, personal fees and other from Pfizer, personal fees from Janssen, personal fees from Aravive, personal fees from VBL Therapeutics, personal fees and other from Onco Med, personal fees from Samumed, grants and other from Lilly, personal fees from Eisai, personal fees from Vavotar, personal fees from Abbvie, personal fees from Tarveda, outside the submitted work. Dr. Thomas Herzog reports personal fees from Johnson & Johnson, personal fees from Clovis Oncology, personal fees from AstraZeneca, personal fees from GSK/Tesaro, personal fees from Roche, personal fees from Caris, personal fees from Abbvie, outside the submitted work. Dr. Angeles Alvarez Secord reports grants from AbbVie, Amgen, AstraZeneca, Clovis Oncology, Astellas Pharma Inc., Boehringer Ingelheim, Bristol-Myers Squibb, Eisai, Endocyte, Exelixis, Incyte, Merck, PharmaMar, Immutep Ltd., Roche/Genentech, Seattle Genetics, Inc., Tesaro/GSK, VBL Therapeutics, National Cancer Trial Network; honoraria from Aravive, AstraZeneca, Clovis Oncology, Cordgenics, Eisai, Janssen/Johnson & Johnson, Merck, Mersana, OncoQuest, Roche/Genentech, Tesaro/GSK Advisory Boards; participation on Clinical Trial Steering Committees (uncompensated) for Roche/Genentech, and VBL Therapeutics; and member of GOG-Foundation Board of Directors, outside the submitted work. Dr. Ursula A. Matulonis reports personal fees from AstraZeneca, Myriad Genetics, Clovis Oncology, Merck, Eli Lilly, Mersana, Geneos, Fuji Film, Cerulean, Immunogen, and 2× Oncology. Dr. Brian M. Slomovitz reports receiving consulting fees from AstraZeneca, Clovis Oncology, Incyte, Janssen, GSK/Tesaro, and Genentech/Roche. Dr. Saketh R. Guntupalli reports receiving consulting fees from AstraZeneca, Clovis Oncology, and Tesaro. Dr. David O'Malley reports personal fees and other from AstraZeneca, personal fees and other from Clovis Oncology, personal fees and other from Tesaro, personal fees and other from Immunogen, personal fees from Ambry, personal fees and other from Janssen/Johnson & Johnson, personal fees and other from Abbvie, personal fees and other from Regeneron, personal fees and other from Amgen, personal fees and other from Novocure, personal fees and other from Genentech/Roche, other from VentiRx, other from Array Biopharma, other from EMD Serono, other from Ergomed, other from Ajinomoto Inc., other from Ludwig Cancer Research, other from Stemcentrx, Inc., other from CERULEAN PHARMA, other from GOG Group, other from Bristol-Myers Squibb, other from Serono Inc., other from TRACON Pharmaceuticals, other from Yale University, other from New Mexico Cancer Care Alliance, other from INC Research, Inc., other from inVentiv Health Clinical, other from Iovance, other from PRA Intl, other from Agenus, outside the submitted work. We thank A. Peter Morello III, Ph.D. (Clovis Oncology, Inc., Boulder, CO, USA) for assistance with preparation of this correspondence.