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“Ask Me Anything” with Dr. David Gershenson. Join Now!

“Ask Me Anything” with Dr. David Gershenson. Join Now!

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86 Replies

I am currently taking Carbo/Taxol/Avastin for recurrent granulosa cell tumor. What other treatment options are available besides chemotherapy? I received Carbo/Taxol 2013 and was rediagnosed in 2017. I am interested to see if hormone therapy would be an option if I am estrogen negative and focally <10% progesterone positive. Your thoughts?

Other than chemotherapy, hormonal therapy--aromatase inhibitors, tamoxifen, leuprolide, etc.--have shown activity. The response to hormonal therapy does not necessarily correlate with estrogen receptor status.

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Thank you all for joining us today. Please, Dr. Gershenson, tell us about yourself

Thank you. I am a gyn oncologist practicing at MD Anderson Cancer Center in Houston, TX. My principal area of expertise and research is rare ovarian cancers.

do you have to keep hitting refresh to see his answers?


Yes you should continuously refresh your page

This is Lenore Levy and I would like to ask after I find that the trametiinib dosen't work what other treatments are available? I am on your trail since September 2017 after tamoxifen for 16 months.

It depends on your other prior therapies. Chemotherapy has activity for some patients. Doxil may be particularly active. And, of course, hormonal therapies and bevacizumab are active as well.

Exactly what type of hormonal therapies? I have already done Carbo/Taxol, gemzar; letrozol

Other hormonal therapies include tamoxifen, leuprolide, and fulvestrant. There are other aromatase inhibitors as well, particularly exemestane.

Thanks so much. While on trametinib my recent CT scan showed a small increase in size of tumors yet my CA125 went down from 151 to 91. Can you explain?

There is not always direct correlation between CA 125 and imaging. However, unless the imaging indicated a 20% or greater increase in target lesions, the recommendation would be to remain on the drug. But there occasionally can be some discordance.

Thanks again. One more question: would surgery be indicated to remove the 3+ lesions with one being adjacent to the colon and may require a colostomy if the trametinib does not work or continue with different treatments?

Thank you. The recommendation for secondary cytoreductive surgery is very individual and is dependent on the number of lesions, the number of prior therapies, and the distribution of disease. So you could be a good candidate, but this would require a discussion with your physician.

What are your thoughts on radiation for GCT?

Radiation therapy in GCT has shown some activity. However, today it is used somewhat selectively. For instance, it may be recommended for disease confined to the pelvis or for a very solitary site of disease.

What are the latest treatments for 1C clear cell? What are their predicted 5 year survival rates?

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For stage IC clear cell carcinoma, the recommended therapy is still taxol + carboplatin. In some centers, radiation may be used, but this is not common. There have been clinical trials in recurrent disease with targeted agents. And bevacizumab is active as well.

besides bevacizumab, what other targeted agents are active in clear cell?

A number have been studied, but they have been negative--sunitinib, dasatinib, and a MET inhibitor. There is hope for PI3 kinase and mTOR inhibitors as well as immunotherapy--checkpoint inhibitors.

Hello, thank you in advance for answering questions tonight.

My mother has stage 3B high grade serious ovarian cancer, with BRIP1 mutation. After 1st line treatment, do any PARP inhibitors help treat BRIP1 mutation? What kinds of drugs are most commonly used for this if any? Are there any trials and research going into this BRIP1 mutation?

BRIP1 is one of those mutations of uncertain significance. Currently, unless you on a clinical trial, PARP inhibitors are not yet FDA approved for maintenance therapy after first-line treatment. Only after second-line treatment. But that will change. In essence, we do not yet know the answer to your question.

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Is maintenance therapy different for high grade and low grade patients? Are there any similar drugs used for most women in effort to manage recurrance such as Avastin? Is Zejula one of these as well? Thanks again.

Maintenance hormonal therapy is commonly used for low-grade cancers--serous or possibly endometrioid. However, a recent study also indicated benefit in high-grade serous carcinoma. Of course, bevacizumab has been used in both high-grade and low-grade with benefit in some patients. Zejulia may be effective and is FDA approved after second line therapy.

I am stage 2b low grade serous, diagnosed September 2017. I have had optimal debulking and am now NED and on letrozole. Have opted not to have chemo but am now wondering whether the benefits of chemo outweigh the risks for what is usually considered a low response rate to chemo for low grade serous?

Thank you. It is true that low-grade serous carcinoma is not as sensitive to chemotherapy as high-grade serous ca. However, it does not mean that it is totally insensitive. Many physicians are recommending hormonal therapy instead of chemotherapy after primary surgery. A randomized trial is currently proposed to compare chemotherapy followed by hormonal therapy versus hormonal therapy.

Are there any vaccines to prevent Ovarian Cancer recurrence in clinical trials in the USA at this time. TobyG

The have been and are vaccine trials for ovarian cancer at various centers. Some are treatment trials, others for prevention of recurrence or maintenance. But they will vary greatly. Nothing is yet ready for prime time.

How can someone find out about where those trials are and if they are eligible?

Great question. is probably the best place, but it does not list all trials. It does include eligibility. Otherwise, one has to search the web sites of major cancer centers. Not easy, and people are working on a more robust web site. Not there quite yet.

SHARE also offers a clinical trial matching service to help you locate trials. go to:

Will anti estrogen meds such as Femara or letrozole help in preventing recurrence for endometriod adenocarcinoma?

Great question. There have not been any clinical trials to prove this. However, particularly for a grade 1 or 2 endometrioid carcinoma, hormonal therapy may be effective. NRG Oncology is considering clinical trials for this subtype in the future.

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Thank you for your reply. I Appreciate it!

Dr. Gershenson, what is your protocol for following low grade ovca, since it doesn't show on scans, doesn't necessarily raise CA125. What standard do you follow for checkups? My CA125 is checked once a year and a pelvic is done, that's it. No symptoms at first diagnosis 6 years ago.

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Thank you. It depends on time from diagnosis. If you are 6 years from diagnosis and without disease, I would recommend every 6 months; others would recommend annually. I would still recommend CA 125 and scans.

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Clinical trials for rare ovarian cancers are hard to find. What key words should we search for trials to include Granulosa Cell Tumor?

I agree. Too few. Either granulosa cell tumor or sex cord-stromal ovarian tumors.


Dx with Primary Peritoneal cancer and ovarian cancer Stage IIIC high grade serous - total hysterectomy and numbers down to 12 when done with treatment at end of 2016. Six months later, numbers going back up with scalloping on the liver. Finishing sixth set of Carbo and Gemzar and numbers dropping again. How effective are PARP inhibitors and what do you think of HIPEC treatment? This was suggested by second opinion doctor at Mayo in Jacksonville. My Moffit doctor didn't give me a good prognosis.

PARP inhibitors can be effective in at least delaying recurrence after second-line chemotherapy with response. They are increasingly being recommended. As for HIPEC, it has been considered experimental. However, an article was just published in the New Eng J Medicine showing benefit in terms of outcome compared to no HIPEC.

Thank you for that info. I am keeping strong and healthy as possible given my diagnosis.

Please advise us what HIPEC stands for. Thanks TobyG

Hyperthermic intraperitoneal chemotherapy (HIPEC) is a highly concentrated, heated chemotherapy treatment that is delivered directly to the abdomen during surgery

Hyperthermic Intraperitoneal Chemotherapy - HIPEC

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I recently started anastrozole for recurrent GCT. I'm a little confused with the estrogen receptor vs progesterone receptors and medications to suppress tumor growth. If anastrozole is for suppressing estrogen, but a tumor is moderate progesterone receptor positive & weak estrogen receptor positive, will it still help?

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Great question. The status of estrogen or progesterone receptor does not necessarily correlate with response to hormonal therapies, so yes, it could still help and is worth a trial.


If receptor status does not necessarily correlate, how do you determine which hormone therapy would be most successful?


Unfortunately, it is empirical--trial and error. The hope is that with further studies, we will have a better handle on the correlation.


Thank you so much. One more question.

Is Anastrozole a reasonable hormonal therapy to start with? And should it be combined with something else? I see a lot of ladies with GCT are on more than one medication to suppress growth, while I am only on this one.

We do not yet know which hormonal therapy is the best. But letrozole is a very reasonable choice. Again, it is empirical. You should not be concerned about being on one drug only.

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Just to clarify, you said that letrozole is a very reasonable choice to start with, but I'm on anastrozole. I know they are similar, but I didn't think they were the same. Should I look into switching to letrozole instead of the anastrozole?

OK, sorry. Did not notice that you were on anastrozole. No, do not switch. They are both aromatase inhibitors and thought to be equivalent. So either is fine.

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Hi I was diagnosed stage 2A grade 2 endometrioid adenocarcinoma in 2016. Dense dose Chemo completed . Currently NED . Will anti-estrogen pills such as femara help with preventing recurrence? Also is stage 2 curable with endometrioid adenocarcinoma?

Because of the rarity of this subtype, there have been no clinical trials to prove this or even much retrospective data. However, I do believe that it may be worthwhile as a maintenance therapy following chemotherapy. Fortunately, most women tolerate reasonably well.

-Dr. Gershenson

Do you recommend a specific one to try?

We don't the best therapy, but letrozole would be very reasonable to start.

Stage Ii dx. 2011 of endometrioid ovca. I’ve had 3 surgeries, total of 9 infusions of carbo/taxol and 6 of Doxil, then 10 radiations. Is endometrioid ovca getting any research attention? I’m grateful for your response

Thank you. The NRG Oncology Rare Tumor Committee just discussed this subtype at its meeting last week and would like to develop a clinical trial. It is challenging because of the extreme rarity of this subtype, but I believe that it is feasible. So stay tuned.

Because of the rarity of this subtype, there have been no clinical trials to prove this or even much retrospective data. However, I do believe that it may be worthwhile as a maintenance therapy following chemotherapy. Fortunately, most women tolerate reasonably well.

There is currently no research in the U.S. on granulosa cell tumor and potential treatments. How do we interest a researcher in taking this on?


There is interest by researchers in both the US and also in Europe and Australia. The major challenge is getting pharmaceuticals to support trials through funding. The NCI has supported a few trials--bevacizumab, taxol, etc. And currently there is a randomized phase II trial of BEP versus taxol/carboplatin for newly diagnosed stage III and IV. So there are researchers who are interested.

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Hello-I am 15 months post chemo for stage 3B MMMT. So far I am NED. I did 6 cycles of carboplatin and taxol. Statistically what can I expect at this point? What are the new treatments for this rare cancer that are showing promise?

MMMT is quite rare. There are very few clinical trials specifically for this subtype. Molecular testing of the tumor may identify common mutations that could be targets for novel therapies. Generally, these tumors are treated the same as high-grade serous carcinomas and have similar behavior.

I have heard terms such as PARP inhibitors, maintenance drugs, hormone therapy, immunotherapy, combinations, and so on. Does every woman have access to all these options in her treatment? And is there anything that one can do to support the liver or kidneys due to receiving chemo and any other medication? Thank you again.

Great question. The choice of therapy is dependent on several factors--type of ovarian cancer, prior treatments, setting, etc. So, for instance, the treatments you list may or may not apply to every woman. The key is to personalize therapy based on a patient's characteristics. But all of the options you mention are of interest and in clinical trials.

When a person has a tumor against the colon or Maybe I should say in contact with the colon. How long does. it take to attach to the colon and put a hole in the colon on average. Diagnosed with stage 3c low grade serous cancer since 2015.

It is not unusual to have tumor implants on the surface of either the colon or small intestine. Generally, they do not invade completely into the lumen of the bowel, but that can occur sometimes and may be associated with bleeding. If the masses become too large, they can cause obstruction and may require surgery.

Diagnosed with stage 4 ovarian cancer on December 2016. I received both neoadjuvant (Carbo, Taxol and Avastin) and adjuvant (Cisplatin, Taxol and Avastin) chemotherapy. I am currently in remission but I’m receiving maintenance Avastin monthly. Would I be eligible for a Stage II clinical trial exploring benefits of Avastin plus PARP inhibitor to extend remission? If not, are there any other options/trials available?

If you are currently receiving Avastin maintenance therapy, once you finish, you would not likely be eligible for a clinical trial unless you developed a recurrence. Later, further chemo and a PARP inhibitor could be options for you, if necessary.

What can I expect after six cycles of carboplatin/taxol for ovarian cancer stage 1A high grade serous carcinoma? When will I begin to feel normal? Will I ever? What are the chances of recurrence?

Generally, it takes about 3 months to begin to feel pretty normal after completing chemotherapy. The chances of recurrence are in the range of 10-20%.

Is there a role for some of the bucket trials out there for some of the rarer ovarian cancers?

Yes, definitely. The NCI-MATCH trial is one. ASCO has also started another. These require molecular testing of the tumor to identify common mutations. Eligibility is dependent on matching a specific drug to a mutation. Google them.

Have the standard protocols for GCT changed? My understanding is BEP is preferred but often substituted with Carbo/Taxol as the 1st treatment following debulking surgery. I'm stage 3, have had 4 surgeries, tried carbo/taxol (allergic to both taxol & taxotere) so did single agent carbo. Anastrozole had no benefit. Had great initial response to megace but 2 months later markers started rising. Still on megace and added tamoxifen. Just curious if there is a treatment that is looking positive that I could discuss with my gyn onc,

Initial treatment generally consists of either BEP or taxol/carboplatin. These are being compared in phase II trial. Avastin (bevacizumab) also has activity and could be considered. We are also trying to develop a trial in NRG Oncology with cediranib, an oral anti-angiogenic. If you haven't already, have molecular testing of the tumor.

I have had the CARIS testing. Right now my doc is a little baffled by my results. AMH & Inhibin A rising and Inhibin B falling. I am PR+ and ER-.

what are the recurrence stats for low grade serous (diagnosed as 2b)

Are blood pressure medicines such as beta blockers helpful to preventing recurrence? I heard a study was done and it showed promise. Is it a certain type of beta blocker?

There is quite a bit of information suggesting benefit from beta blockers. However, they are not currently being used routinely. In the future, there may be clinical trials.

What’s being done to help understand and alleviate side effects from AIs?

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There are medications to help with side effects--for hot flashes and vaginal dryness. Otherwise, one may need to change to a different AI, which sometime will help.

And if have similar side effects on all—specifically joint and muscle pain that makes life miserable. Something needs to be done to address it. It is difficult to continue. Quality versus quantity of life should not be a decision we are forced to make over AIs


What’s current research on treatment and data on recurrence and survival rates for transitional cell carcinomas?

Pathologists have recently suggested folding transitional cell carcinomas into the high-grade serous category. So not much research ongoing right now. They do seem to have a better overall prognosis and some association with BRCA mutations.

Thank you, Dr. Gershenson for being apart of our Ask Me Anything. It is greatly appreciated. We are no longer taking anymore question. Everyone, please follow the link to answer survey:

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