Risk Management & Treatment

Biomarkers, targeted and immunotherapies for fallopian tube, ovarian and primary peritoneal cancer

This section covers the following topics:


Genetic tests for inherited mutations for treatment selection

Genetic testing for an inherited mutation may be used to guide treatment selection for people diagnosed with ovarian cancer.  

  • People with advanced recurrent ovarian cancer who test positive for an inherited BRCA1 or BRCA2 mutation may benefit from treatment with a type of targeted therapy known as a PARP inhibitor.
  • People who test positive for other inherited gene mutations may qualify for clinical trials looking at targeted therapies to treat hereditary ovarian cancer. 
  • People who test positive for a Lynch syndrome gene mutation may benefit from treatment with an immunotherapy agent. 


Biomarker testing 

Biomarker tests look at samples of blood, tumor or other tissue for changes or abnormalities caused by cancer. These tests can give doctors clues about the cancer, including:

  • how fast the cancer is growing
  • which treatments are most likely to work
  • whether or not the cancer is responding to treatment or growing
  • whether or not the cancer has come back after remission

Biomarker tests may be used to select treatments, and help patients avoid side effects from treatments that will not work for them. Biomarker tests used to select a specific treatment are sometimes called companion diagnostic tests. These tests may be done on tumor tissue or (in many cases) on blood. See our Biomarker Testing section for more information. 


Biomarkers for treatment selection

Examples of biomarker tests used in fallopian tube, ovarian and primary peritoneal cancer include:

  • Tests can be done to look for BRCA1 or BRCA2 gene mutations in the tumor. Women who test positive for a BRCA1 or BRCA2 mutation in their tumor may benefit from a type of therapy known as a PARP inhibitor. A tumor test positive for a BRCA1 or BRCA2 mutation in one of two situations:, 
    • when women who have an inherited mutation in BRCA1 or BRCA2 develop ovarian cancer, their tumor is very likely to display the same mutation.
    • women who test negative for an inherited mutation in BRCA1 or BRCA2 may still develop an acquired BRCA mutation in their tumor. Women with a BRCA mutation in their tumor may also respond well to PARP inhibitor treatment.  
  • Some ovarian cancers will have an abnormality known as MSI-high (microsatellite instability high") also known as "mismatch repair deficiency" (dMMR or MMR-D). MSI-high cancers are common in people with a Lynch syndrome gene mutation. These cancers may respond well to a type of treatment known as an immune checkpoint inhibitor. One example of an immunotherapy agent used for MSI-H cancers is Keytruda (pembrolizumab).


Biomarkers to monitor recurrence or response to treatment

CA125 is a type of protein that is produced in large amounts by some ovarian cancers. Doctors may use CA125 blood tests monitor recurrence or response to treatment. 


Immunotherapies 

Immunotherapies are cancer treatments that hlep the body’s immune system detect and attack cancer cells. There are several different categories of immunotherapies. 

  • Keytruda (pembrolizumab) is known as an immune checkpoint inhibitor. approved for treatment of patients with metastatic cancer that tests MSI-high. Although this biomarker is not common in ovarian cancer, it is often seen in people with a Lynch syndrome gene mutation who develop cancer. 


Targeted therapies

Two types of targeted therapies are commonly used to treat advanced ovarian cancer:

  • Avastin (bevacizumab)
  • PARP inhibitors


Avastin

Avastin is a targeted therapy that works by cutting off the blood supply to the cancer. It may be given as treatment in combination with chemotherapy, or as maintenance therapy after treatment alone or in combination with Lynparza.


PARP inhibitors 

PARP inhibitors work by blocking a protein used by cells to repair damaged DNA. They were initially developed to treat cancers in people with an inherited gene mutation BRCA1 or BRCA2 mutation. Three PARP inhibitors have been approved for treating ovarian cancer:

  • Lynparza (olaparib)
  • Rubraca (rucaparib)
  • Zejula (niraparib)

PARP inhibitors have received approval for treating ovarian cancer in two settings:

  • as treatment of advanced, recurrent ovarian cancer
  • after chemotherapy as maintenance therapy for advanced ovarian cancer

Research is ongoing to learn if PARP inhibitors are also affective for treating ovarian cancer in other situations, including:  

  • people with an inherited mutation in a different gene that repairs DNA damage (for example: PALB2, BRIP1, RAD51C, RAD51D).
  • people who do not have an inherited gene mutation, but tumor biomarker testing found an acquired tumor mutation in a gene that repairs DNA damage.
  • in combination with immunotherapy or other agents.


PARP inhibitors for treatment of advanced, recurrent cancer

  • For treating people with advanced, recurrent ovarian cancer, two PARP inhibitors have received FDA-approval as targeted therapy for treating people with a BRCA mutation. The two approved drugs are:
    • Lynparza (olaparib)
    • Rubraca (rucaparib)


Maintenance therapy

Maintenance therapy is given after chemotherapy to try to keep the cancer from returning. The goal is to extend the length of time before recurrence or to turn remission into a long-term cure. 

Table of targeted and immunotherapies for fallopian tube, ovarian and primary peritoneal cancer

Name of drug Type of agent Line of therapy Indication Biomarker
Avastin
(bevacizumab)
Monoclonal antibody targeting vascular endothelial growth factor (VEGF) First-line maintenance Combined with Lynparza (olaparib) for platinum-sensitive cancer Homologous Recombination Deficiency 
(HRD) testing
Avastin
(bevacizumab)
Monoclonal antibody targeting vascular endothelial growth factor (VEGF) First-line Combined with chemotherapy, followed by Avastin as a single agent following initial surgical resection No biomarker required
Avastin
(bevacizumab)
Monoclonal antibody targeting vascular endothelial growth factor (VEGF) Second or third-line Combined with chemotherapy for platinum-resistant recurrent disease  No biomarker required
Avastin
(bevacizumab)
Monoclonal antibody targeting vascular endothelial growth factor (VEGF) Second-line or later Combined with chemotherapy, followed by Avastin as a single agent, for platinum-sensitive recurrent diesase No biomarker required
Lynparza
(olaparib)
PARP inhibitor First-line maintenance For women who had a complete or partial response to platinum chemotherapy Inherited or acquired (tumor) mutation in BRCA1 or BRCA2
Lynparza
(olaparib)
PARP inhibitor First-line maintenance Combined with Avastin (bevacuzimab) for women who had a complete or partial response to platinum chemotherapy Homologous Recombination Deficiency 
(HRD) testing
Zejula PARP inhibitor First-line maintenance For women who had a complete or partial response to platinum chemotherapy No inherited or acquired mutation or other tumor
biomarker needed

Lynparza
(olaparib)

Rubraca
(rucaparib)

Zejula
(niraparib)

PARP inhibitor Second-line or later maintenance For platinum-sensitive or partially sensitive recurrent cancer  No inherited or acquired mutation or other tumor
biomarker needed
Rubraca
(rucaparib)
PARP inhibitor Third-line or later treatment For treatment of advanced, recurrent ovarian cancer Inherited or acquired (tumor) mutation in BRCA1 or BRCA2
Lynparza
(olaparib)
PARP inhibitor Fourth-line or later treatment For treatment of advanced, recurrent ovarian cancer Inherited mutation in BRCA1 or BRCA2
Zejula
(niraparib)
PARP inhibitor Fourth-line or later treatment For treatment of advanced, recurrent ovarian cancer BRCA mutation or
HRD-positive
Keytruda (pembrolizumab) Immune checkpoint inhibitor Metastatic or  unresectable solid tumors For treatment of solid tumors that have progressed after treatment and for which there are no other treatment options Microsatellite Instability High (MSI-H) or Mismatch Repair Deficiency (MMR-D
Keytruda (pembrolizumab) Immune checkpoint inhibitor Metastatic or  unresectable solid tumors For the treatment of solid tumors that have progressed after treatment and for which there are no other treatment options Tumor Mutational Burden High (TMB-H)
paying-for-service

The majority of public and private health insurance plans are required to cover cancer diagnosis and treatment; copays, coinsurance and deductibles often apply. Patient costs and coverage for specific doctors, facilities or treatments may vary based on your health plan. Visit our section on Insurance and Paying for Care: Treatment  for more information, links to sample appeal letters and other resources. 

Some pharmaceutical companies and laboratories have assistance programs that help cover the cost for their medications, tumor testing or genetic testing for an inherited mutation: 

Organizations that offer co-pay assistance:

Other resources:

  • The American Cancer Society provides information and resources on covering the cost of cancer care. Public assistance, such as Medicaid may be available if you are ineligible for other programs. 
  • Needy Meds: Assistance programs to help patients with cost of medications and other healthcare.
  • Triage Cancer offers tools and resources to help individuals cope with the financial aspects of a cancer diagnosis.
clinical-trials

The following studies may be of interest to women with ovarian cancer and an inherited mutation. 

Advanced solid tumors of any type 

Ovarian cancer

Visit our Research Search and Enroll Tool to find additional cancer treatment studies.